A nurse is teaching a client's spouse about how to obtain a blood pressure reading. Which of the following actions by the spouse indicates a need for further instruction?

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 snugly around the client's arm.

Checks the instrument gauge to ensure the reading starts at zero.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Placing the cuff bladder over the client's brachial artery is a correct action when obtaining a blood pressure reading. This choice demonstrates proper cuff placement, which is essential for an accurate measurement.

Choice B rationale:

Placing the client's arm above the level of the client's heart is an incorrect action when obtaining a blood pressure reading. The client's arm should be supported at heart level to ensure accurate measurement. This choice indicates a need for further instruction as it could lead to an artificially low blood pressure reading.

Choice C rationale:

Wrapping the blood pressure cuff snugly around the client's arm is a correct action when obtaining a blood pressure reading. This choice demonstrates proper cuff application, which is necessary for accurate results.

Choice D rationale:

Checking the instrument gauge to ensure the reading starts at zero is a correct action when obtaining a blood pressure reading. This choice reflects a proper step to verify that the equipment is calibrated correctly.

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Correct Answer is D

Explanation

Choice A rationale:

The choice "Pigeon" is not the correct answer. Pigeon chest, also known as pectus carinatum, is a deformity of the chest characterized by a protrusion of the sternum and ribs. This condition is not associated with chronic bronchitis.

Choice B rationale:

The choice "Funnel" is not the correct answer. Funnel chest, or pectus excavatum, is a deformity where the sternum is sunken into the chest. It is not the expected chest shape in chronic bronchitis.

Choice C rationale:

The choice "Kyphotic" is not the correct answer. Kyphosis refers to an excessive outward curvature of the thoracic spine, leading to a rounded upper back appearance. This is not the typical chest shape seen in chronic bronchitis.

Choice D rationale:

The correct answer is "Barrel." Choice D is the correct answer. Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by airway inflammation and narrowing. Over time, this can lead to air trapping in the lungs and an increase in the anteroposterior diameter of the chest. This results in a barrel-shaped chest appearance, where the chest appears rounded and the ribs are more horizontal. This adaptation allows for increased lung capacity to accommodate for the compromised airflow in patients with chronic bronchitis.

A. Offer a glass of water to the patient. B. Monitor the patient for signs and symptoms of shock. C. Place moist sterile gauze over the site. D. Gently place the organs back. E. Contact the patient's Surgeon.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale:

Offering a glass of water to the patient is not a priority action when dealing with a surgical incision that eviscerates. This situation requires immediate intervention to prevent complications related to the evisceration.

Choice B rationale:

Monitoring the patient for signs and symptoms of shock is crucial in this scenario. Evisceration, the protrusion of organs from a surgical incision, can lead to significant blood loss, which may result in shock. Signs of shock include hypotension, tachycardia, pallor, diaphoresis, and altered mental status.

Choice C rationale:

Placing moist sterile gauze over the site is appropriate to prevent the exposed organs from drying out and becoming further damaged. It also helps to reduce the risk of infection. Moist sterile gauze helps maintain a sterile environment and prevents the organs from being exposed to contaminants.

Choice D rationale:

Gently placing the organs back into the abdominal cavity is not within the nurse's scope of practice. This action requires surgical intervention by a healthcare provider. The nurse's role is to provide immediate first aid and notify the surgeon.

Choice E rationale:

Contacting the patient's surgeon is essential. Evisceration is a surgical emergency, and the surgeon needs to be informed promptly to make decisions regarding further interventions. The patient may require emergency surgery to address the evisceration and prevent complications.

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A nurse is teaching a client's spouse about how to obtain a blood pressure reading. Which of the following actions by the spouse indicates a need for further instruction?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient who has chronic bronchitis. The nurse should expect the patient's chest to be which of the following shapes?

Correct Answer is D

Explanation

A nurse on the Medical-Surgical unit is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

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