As the nurse enters the client's room, which is the first priority to assess?

Listen to bowel sounds with a stethoscope

Ask the client to describe their pain

Measure blood pressure, heart rate, and oxygen saturation

Observe the client for signs of respiratory distress or discomfort

Answer and Explanation

The Correct Answer is D

Choice A reason: Auscultation of bowel sounds is a component of a secondary or focused abdominal assessment. While necessary for evaluating gastrointestinal motility, it is not a life-sustaining priority and should only be performed after the nurse has ensured that the patient's airway, breathing, and circulation are stable.

Choice B reason: Assessing pain is an essential part of the "fifth vital sign," but it follows the initial survey of physiological stability. Unless pain is associated with an acute life-threatening event like a myocardial infarction, the nurse must first visually confirm that the patient is breathing and conscious.

Choice C reason: Measuring vital signs provides quantitative data about hemodynamic status, but the initial "doorway" assessment should be a qualitative visual sweep. The nurse must first observe the patient's overall appearance and work of breathing before taking the time to apply equipment and wait for digital readings.

Choice D reason: Immediate visual observation of the patient's respiratory status and level of consciousness is the highest priority upon entering a room. Following the Airway-Breathing-Circulation (ABC) framework, the nurse must quickly identify signs of acute distress, such as cyanosis or accessory muscle use, to intervene before complications escalate.

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Correct Answer is D

Explanation

Choice A reason: Placing a cuff over rolled clothing is incorrect as it can create uneven pressure or a "tourniquet effect" above the cuff. This can distort the transmission of Korotkoff sounds and the accuracy of the pressure sensors, leading to clinical errors in the measurement of systolic or diastolic values.

Choice B reason: A tightened bra strap or any restrictive clothing on the upper torso can interfere with venous return and arterial flow. For an accurate measurement, the arm must be free of any proximal constriction that could artificially alter the pressure required to occlude the brachial artery during the assessment.

Choice C reason: Applying a blood pressure cuff above a vascular access site, such as a dialysis shunt or PICC line, is strictly contraindicated. The pressure exerted by the inflated cuff can cause catheter displacement, vessel damage, or clotting (thrombosis) of the access site, resulting in significant patient harm.

Choice D reason: The cuff should be positioned approximately 2.5 cm (1 inch) above the antecubital space. This placement ensures that the stethoscope diaphragm can be placed clearly over the brachial artery without being muffled by the cuff, while also ensuring the bladder is centered over the artery for even compression.

A. Measure blood pressure while client is lying, sitting, and standing B. Record any drop in systolic BP of 20 mmHg or more C. Provide water before the test D. Ask the client to walk during the test E. Wait 1-2 minutes between each position change

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

Explanation

Choice A reason: The procedure for detecting orthostatic (postural) hypotension requires sequential blood pressure and pulse measurements in three distinct positions: supine, sitting, and standing. This allow the nurse to observe how the cardiovascular system compensates for the gravitational shifts in blood volume during position changes.

Choice B reason: Orthostatic hypotension is clinically defined as a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within three minutes of standing. Recording these specific drops is essential for a definitive diagnosis of the condition.

Choice C reason: Providing water before the test could artificially inflate the blood volume and mask orthostatic hypotension. The goal of the test is to evaluate the body's baseline compensatory mechanisms. Adding fluids would interfere with the accuracy of the assessment by temporarily correcting potential dehydration-induced hypotension.

Choice D reason: The client must remain still during each measurement to ensure an accurate blood pressure reading. Walking or physical activity during the test would stimulate the sympathetic nervous system and muscular pump, which could falsely elevate the blood pressure and invalidate the results of the orthostatic assessment.

Choice E reason: A brief rest period of 1 to 2 minutes (sometimes up to 3 minutes) between each position change is necessary to allow the blood to redistribute and the baroreceptor reflex to respond. Taking the measurement too quickly would not give the body enough time to show a true postural reaction.

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As the nurse enters the client's room, which is the first priority to assess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To demonstrate correct technique for obtaining a blood pressure, where should the nurse place the blood pressure cuff?

Correct Answer is D

Explanation

A nurse is assessing a client for orthostatic hypotension. Which actions should the nurse take during the assessment? (Select all that apply)

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

Explanation

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