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 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.

A. Wearing gloves before touching the client. B. Using a separate, disposable blood pressure cuff for each client. C. Wearing gloves to palpate the tongue and buccal membranes. D. Wearing a gown, gloves, and mask during assessment.

Correct Answer is C

Explanation

A. Wearing gloves before touching the client is not necessary unless the nurse anticipates contact with bodily fluids, non-intact skin, or mucous membranes.
B. Using a separate, disposable blood pressure cuff is an example of transmission-based precautions, not standard precautions, unless the client has an infection requiring contact precautions.
C. Wearing gloves to palpate the tongue and buccal membranes is correct because standard precautions require gloves when there is potential contact with mucous membranes, which can expose the nurse to infectious agents.
D. Wearing a gown, gloves, and mask is unnecessary unless the client has an infection that requires additional precautions beyond standard precautions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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