The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?

You will need to use a stethoscope properly.

You can move your arm during the reading

You can apply the cuff in any manner

You will need to recalibrate the machine

Answer and Explanation

The Correct Answer is D

A. You will need to use a stethoscope properly. A portable electronic blood pressure device is automatic and does not require the use of a stethoscope. The device detects oscillations in arterial pressure to provide a reading.

B. You can move your arm during the reading. Movement during the reading can interfere with accuracy and produce incorrect results. The patient should keep the arm still and at heart level.

C. You can apply the cuff in any manner. The cuff must be applied correctly—snug but not too tight, with the lower edge about 1 inch above the antecubital fossa, and the bladder of the cuff positioned over the artery—to ensure accurate readings.

D. You will need to recalibrate the machine. Electronic blood pressure devices require periodic recalibration to maintain accuracy. The patient should follow the manufacturer’s guidelines for recalibration and compare readings with a manual blood pressure check at clinic visits.

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Correct Answer is A

Explanation

A. Respirations: C4 injuries compromise the phrenic nerve, which controls the diaphragm. A high cervical spine injury can lead to respiratory failure, making airway and breathing the top priority.

B. Pulse: While monitoring circulation is important, breathing takes priority in a C4 injury due to the risk of respiratory paralysis.

C. Temperature: Temperature regulation may be affected due to autonomic dysfunction, but airway and breathing remain the priority.

D. Blood Pressure: While spinal cord injuries can cause neurogenic shock (low BP, bradycardia), ensuring airway and breathing comes first.

A. Aortic and Mitral B. Mitral and Pulmonic C. Mitral and Tricuspid D. Aortic and Pulmonic

Correct Answer is D

Explanation

A. Aortic and Mitral: The mitral valve is associated with the S1 sound, not S2. S2 occurs when the semilunar valves (aortic and pulmonic) close.

B. Mitral and Pulmonic: The mitral valve closure is heard in S1, while the pulmonic valve closure is part of S2. However, the mitral valve is not involved in S2.

C. Mitral and Tricuspid: The mitral and tricuspid valves close during S1, not S2. These valves are atrioventricular (AV) valves, not semilunar valves.

D. Aortic and Pulmonic: The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves at the beginning of diastole. This marks the end of systole.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority?

Correct Answer is A

Explanation

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?

Correct Answer is D

Explanation

A patient has been diagnosed with heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output?

A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication?

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage.

A patient who has been taking antihypertensive drugs for a few months states that a new, persistent dry cough is very bothersome. The nurse knows that this cough is an adverse effect of which class of antihypertensive drugs?

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?

The nurse is completing an assessment of the patient's skin integrity. Which assessment is the priority?

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.)