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 C
Explanation
A. Discuss that a light will be directed at the neck to observe for pulsations of the artery:
This choice is incorrect. Directing light at the neck is not a standard method for assessing carotid artery pulsations. The carotid artery is usually assessed by palpation to feel the pulse rather than visual observation.
B. Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates:
This choice is incorrect. Auscultation is typically not used to assess carotid artery pulsations. Palpation (feeling the pulse) is the primary method used for this assessment.
C. Demonstrate that both arteries will be palpated simultaneously to compare amplitude:
This choice is correct. Palpating both carotid arteries simultaneously allows the nurse to compare the amplitude (strength) of the pulses. This comparison helps in assessing the symmetry of the pulses and ensures there are no significant differences between the two sides, which could indicate vascular abnormalities.
D. Show the client the diaphragm of the stethoscope that will be placed on the neck:
This choice is incorrect. The diaphragm of the stethoscope is not typically used for palpating pulses. Palpation involves using the fingertips to feel the pulse and assess its strength and regularity.
Correct Answer is C
Explanation
In this sequence:
Vena cava brings deoxygenated blood from the body into the right atrium.
Blood flows from the right atrium to the right ventricle through the tricuspid valve.
The right ventricle pumps blood into the pulmonary artery to the lungs.
In the lungs, blood is oxygenated and returns to the heart via the pulmonary veins into the left atrium.
From the left atrium, blood moves to the left ventricle through the bicuspid (mitral) valve.
The left ventricle then pumps oxygenated blood into the body through the aorta.
This sequence represents the systemic and pulmonary circulation of the heart.
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