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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Stage I Pressure ulcer - This choice is not correct because a Stage I pressure ulcer is characterized by intact skin with non-blanchable redness over a bony prominence. There is no partial-thickness skin loss at this stage.
Choice B rationale:
Stage II Pressure ulcer - This is the correct choice. A Stage II pressure ulcer involves partial-thickness skin loss that presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also manifest as an intact or open/ruptured serum-filled blister.
Choice C rationale:
Stage IV Pressure ulcer - This choice is not correct because a Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. There is no mention of such extensive tissue loss in the given scenario.
Choice D rationale:
Stage II Pressure ulcer - This choice is a duplicate of Choice B and is not correct for the reasons stated above.
Correct Answer is C
Explanation
Choice A rationale:
Decreased tactile fremitus refers to a decreased vibration felt upon palpation of the chest, which might be indicative of conditions such as pleural effusion or pneumothorax. It is not directly associated with a crackling sensation.
Choice B rationale:
Pleural friction fremitus occurs when inflamed pleural surfaces rub against each other during breathing. It typically results in a grating sensation rather than a crackling sensation. It is associated with conditions like pleuritis.
Choice C rationale:
(Correct Choice) Crepitus refers to a crackling or grating sound/sensation that occurs when gas or air accumulates in the subcutaneous tissue. It can indicate a serious condition, such as subcutaneous emphysema, which might result from lung or chest wall injury, infections, or surgery.
Choice D rationale:
Rhonchal fremitus is associated with coarse breath sounds caused by thick secretions in the larger airways. It is felt as vibration during palpation and is not related to crackling sensations.
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