The nurse is assessing vital signs and is preparing to measure the client's blood pressure. Prior to obtaining the blood pressure, what action would be most appropriate?

Inflate the blood pressure cuff 30 mmHg above the point where the radial pulse disappears.

Assist the patient to a standing position for five to ten minutes.

Palpate the radial artery and place your stethoscope lightly over this area.

Measure the blood pressure cuff, ensuring that the cuff encircles 60% of the client’s arm.

Answer and Explanation

The Correct Answer is A

A. Inflating the blood pressure cuff 30 mmHg above the point where the radial pulse disappears is correct. This method, known as the palpatory method, prevents auscultatory gap errors and ensures an accurate blood pressure reading.
B. Assisting the patient to a standing position for five to ten minutes is incorrect unless assessing for orthostatic hypotension. For routine blood pressure measurements, the client should be seated and at rest for at least five minutes.
C. Palpating the radial artery and placing the stethoscope lightly over this area is incorrect because blood pressure is auscultated over the brachial artery, not the radial artery.
D. Measuring the blood pressure cuff to encircle 60% of the client’s arm is incorrect. The correct guideline is that the cuff bladder should encircle at least 80% of the arm circumference, not 60%.

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Correct Answer is C

Explanation

A. Vesicular breath sounds are soft, low-pitched sounds heard over most of the lung fields, characterized by a longer inspiratory phase and shorter expiratory phase.
B. Adventitious breath sounds refer to abnormal breath sounds such as crackles, wheezes, and rhonchi, but the described sound is a normal breath sound in the tracheal region.
C. Bronchial breath sounds are correct. These are high-pitched, harsh sounds with a short inspiratory phase and a long expiratory phase, normally heard over the trachea.
D. Bronchovesicular breath sounds are moderate in pitch and intensity, heard over the major bronchi rather than the trachea. They have equal inspiration and expiration durations rather than a longer expiratory phase.

A. "What makes your pain better?" B. "How long have these episodes been occurring?" C. "What other symptoms are you experiencing during these episodes?" D. "When did the pain begin?"

Correct Answer is B

Explanation

A. Asking what makes the pain better helps determine relief measures but does not specifically address the pattern of occurrence.
B. Asking how long these episodes have been occurring helps identify the pattern of the pain, including its frequency and duration, which is important for diagnosing chronic or recurrent conditions such as migraines or hypertension-related headaches.
C. Asking about other symptoms helps assess associated conditions but does not directly focus on the pattern of the pain.
D. Asking when the pain began helps determine onset but does not provide insight into its recurrence or fluctuation over time.

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The nurse is assessing vital signs and is preparing to measure the client's blood pressure. Prior to obtaining the blood pressure, what action would be most appropriate?

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Naxlex Comprehensive Predictor Exams

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

Correct Answer is C

Explanation

A 40-year-old client is seen at the clinic with a headache and blurred vision that comes and goes. The client reports a pain of a 6 on a scale from 0–10. What question should the nurse ask to obtain more information about the pattern of the pain?

Correct Answer is B

Explanation

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