A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg. client sitting up in a chair." Which of the following information should the nurse clarify?

Systolic blood pressure

Location of blood pressure cuff

Unit of measurement

Position of the client

Answer and Explanation

The Correct Answer is B

A.   The systolic blood pressure is clearly stated as "102 mm Hg" in the documentation. There is no need for clarification regarding the systolic value.
B.   It is essential to document the site where the blood pressure was taken, as this can affect the accuracy of the reading. Typically, the blood pressure is measured in the brachial artery in the upper arm. If the cuff was placed on a different site, such as the wrist or ankle, this should be noted in the documentation.
C.   The unit of measurement for blood pressure is correctly indicated as "mm Hg" (millimeters of mercury). There is no need for clarification regarding the unit since it is standard and clear.
D.   The position of the client is correctly documented as sitting up in a chair.

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Correct Answer is C

Explanation

A. While important for health, this choice is more about healthcare access rather than the social and community context that affects health outcomes.
B. This relates to educational resources but is not a primary example of the social context affecting health directly.
C. Access to transportation affects a person's ability to reach healthcare services, social support, and community resources. It plays a significant role in social interactions and overall well-being, highlighting how transportation availability impacts health outcomes within the community context.
D. While relevant to community health and encouraging physical activity, it focuses more on environmental factors rather than directly addressing social context.

A. Telephone the interpreter that is designated for the facility to interpret the information. B. Use an electronic translating service from the internet to interpret the information. C. Ask the client's partner to interpret the information. D. Call a nursing colleague who speaks the same language as the client to interpret the information.

Correct Answer is A

Explanation

A. Using a designated interpreter ensures that communication is accurate and professional, minimizing the risk of misunderstandings. Facilities often have protocols for accessing interpreters who are trained to handle medical conversations, making this the safest choice.
B. While electronic translating services can be useful, they are not always reliable for medical situations. These services may lack the necessary context for medical terminology and nuances, and they may not ensure confidentiality or accuracy.
C. Involving the client’s partner as an interpreter can lead to issues of accuracy, bias, and confidentiality. The partner may not fully understand medical terminology, and there is a potential for miscommunication or emotional involvement that could affect the interpretation.
D. While this option may seem helpful, it is not ideal. Using a colleague as an interpreter can compromise the confidentiality and professionalism of the interaction. Additionally, the colleague may not have the training necessary to accurately convey medical information, and there might be a conflict of interest.

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A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg. client sitting up in a chair." Which of the following information should the nurse clarify?

Nursing Test Bank

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