The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?
Explain the procedure to the child.
Choose the cuff that says "Child" instead of "Infant."
Use the diaphragm portion of the stethoscope to detect Korotkoff sounds.
Obtain the reading before the child has a chance to settle down
The Correct Answer is A
A. Explain the procedure to the child. Explaining procedures in an age-appropriate manner helps reduce anxiety and increases cooperation. A 3-year-old can understand simple instructions, so explaining what will happen can help them remain calm.
B. Choose the cuff that says "Child" instead of "Infant." Blood pressure cuffs should be appropriately sized for accurate readings. A cuff that is too small can result in falsely high readings, while a cuff that is too large can produce falsely low readings.
C. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. The bell of the stethoscope is best for detecting low-pitched sounds, including Korotkoff sounds.
D. Obtain the reading before the child has a chance to settle down. A child who is upset, crying, or anxious may have an elevated blood pressure reading due to stress. It is best to allow the child to calm down before obtaining an accurate measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Initiate a peripheral IV: While an IV line is useful for medication administration, the patient’s pain has significantly improved with nitroglycerin. An IV may be necessary later, but it is not the next step in this scenario.
B. Administer another nitroglycerin tablet: Nitroglycerin can be repeated every 5 minutes up to 3 doses if chest pain persists or does not decrease significantly. Since the pain has improved (from 6 to 2), additional nitroglycerin is unnecessary.
C. Obtain an ECG/EKG: Even though the pain improved, unstable angina can progress to myocardial infarction. An ECG helps evaluate for ischemic changes and ensures the pain is truly resolving.
D. Call the Rapid Response Team (RRT): RRT should be called for worsening chest pain, unresponsiveness, or hemodynamic instability. Since the pain has improved, calling RRT is unnecessary.
Correct Answer is A
Explanation
A. Assessing changes in body temperature. The RN is responsible for assessing trends in temperature and identifying potential clinical implications (e.g., infection, sepsis, or medication reactions).
B. Being aware of the usual values for the patient. While knowing baseline values is important, this is not solely an RN responsibility. Nursing assistants and other healthcare providers also note baseline values.
C. Obtaining temperature measurements at ordered frequency. This task can be delegated to a nursing assistant or licensed practical nurse (LPN), as it is a routine task that does not require assessment.
D. Using an appropriate route and device. While the RN ensures correct procedures are followed, this specific task can also be performed by trained assistive personnel. The RN focuses on interpretation and intervention.
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