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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The groin is correct because skin folds in obese clients are prone to excessive moisture, which increases the risk of fungal or bacterial infections such as intertrigo. The nurse should inspect these areas for redness, irritation, or signs of infection.
B. The heels are at risk for pressure injuries but are not typically associated with excessive moisture or diaphoresis.
C. The elbows are not a common site for moisture retention and are not a priority for inspection in this case.
D. The toes can be prone to fungal infections (e.g., athlete’s foot), but the primary concern in an obese client with diaphoresis is the skin folds, particularly in the groin and under the breasts.

A. Consult clinical resources explaining the client's diagnosis B. Perform a mini overview of the client's body systems. C. Obtain and organize materials you will need for the assessment. D. Review client's medical record

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.

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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

The nurse is assessing a client with a history of obesity. Upon palpation of the client's skin, the nurse notes diaphoresis. The client reports that, "it is always like that." The nurse should thoroughly inspect the skin on what part of the client's body?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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