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.
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%.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Consulting clinical resources is helpful but should be done after reviewing the client’s specific information.
B. Performing a mini overview of body systems occurs during the assessment, not before meeting the client.
C. Gathering materials is important but comes after understanding the client’s history.
D. Reviewing the client’s medical record is correct because it helps the nurse gather baseline information, understand past medical history, and prepare for the assessment effectively.
Correct Answer is A
Explanation
A. Asking about regular painkiller (NSAID) use is correct because nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen are a major risk factor for peptic ulcer disease. They can damage the gastric mucosa and increase acid production, leading to ulcer formation.
B. Vitamin supplements are not a common cause of peptic ulcer disease. While some supplements can cause gastrointestinal discomfort, they are not a primary risk factor.
C. High-fat foods can contribute to acid reflux or indigestion but are not a direct cause of peptic ulcers. Peptic ulcer disease is primarily linked to Helicobacter pylori infection and NSAID use.
D. Stress was once thought to be a major cause of ulcers, but current research indicates that it plays a minor role compared to factors like H. pylori infection and NSAID use.
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