A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?
Checks the instrument gauge to ensure the reading starts at zero
Centers the cuff bladder over the client's brachial artery
Places the client's arm above the level of the client's heart
Wraps the blood pressure cuff around the client's arm using firm pressure
The Correct Answer is C
A. Checks the instrument gauge to ensure the reading starts at zero:
This action is correct. Before taking a blood pressure reading, it's essential to ensure that the instrument's gauge starts at zero. This ensures accurate measurement as the reading reflects the pressure above zero.
B. Centers the cuff bladder over the client's brachial artery:
This action is correct. Proper placement of the blood pressure cuff over the brachial artery is crucial for accurate readings. Centering the cuff ensures that the artery is correctly compressed for measurement.
C. Places the client's arm above the level of the client's heart:
This action is incorrect. Placing the arm above heart level can result in a falsely low blood pressure reading. The arm should be at the same level as the heart to obtain an accurate measurement.
D. Wraps the blood pressure cuff around the client's arm using firm pressure:
This action is correct, but it's important to note that while the cuff should be snug, it should not be too tight or too loose. Wrapping the cuff with firm, even pressure ensures proper compression of the artery for an accurate measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. When bronchial breath sounds are auscultated in the trachea.
Auscultating bronchial breath sounds in the trachea is a normal finding, as the trachea is close to the upper airway, and this is where bronchial sounds are normally heard. However, if these sounds are heard in the peripheral lung fields, it can indicate an abnormal condition.
B. When the client is experiencing excessive sneezing from a tree pollen allergy.
Excessive sneezing due to allergies would not typically result in increased breath sounds. Allergies may cause nasal congestion, but they don't directly lead to increased breath sounds.
C. When the client is resting in bed and not experiencing respiratory issues.
If a client is at rest and not experiencing any respiratory issues, breath sounds should typically be normal. There would be no reason to expect increased breath sounds in this scenario.
D. When the bronchial tree is obstructed by secretions.
Increased breath sounds, such as wheezing or rhonchi, can be auscultated when there is an obstruction in the bronchial tree due to secretions, narrowing of the airways, or other causes. These sounds are typically abnormal and indicate an issue with air movement through the airways.
Correct Answer is B
Explanation
A. Glandular tissue, which supports the breast by attaching to the chest wall: Glandular tissue is indeed a part of the breast structure, but it is not responsible for supporting the breast by attaching to the chest wall. It's the Cooper's ligaments, which are fibrous connective tissue, that provide structural support.
B. Fibrous, glandular, and adipose tissues: This statement is correct. The breast is composed of glandular tissue (responsible for milk production), fibrous tissue (including Cooper's ligaments for support), and adipose tissue (fat).
C. Primarily muscle with very little fibrous tissue: The breast contains very little muscle tissue. The main supportive structure is fibrous tissue, not muscle.
D. Primarily milk ducts, known as lactiferous ducts: Milk ducts are part of the glandular tissue and are responsible for carrying milk. However, the breast is not primarily made up of milk ducts; it consists of a combination of glandular, fibrous, and adipose tissues.
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