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 ["1170"]
Explanation
Step 1: Convert cups and ounces to mL (1 cup = 240 mL, 1 oz = 30 mL):
- Coffee: 1 cup = 240 mL
- Orange juice: 4 oz × 30 mL = 120 mL
- Water (first): 3 oz × 30 mL = 90 mL
- Flavored gelatin: 1 cup = 240 mL
- Tea: 1 cup = 240 mL
- Broth: 5 oz × 30 mL = 150 mL
- Water (second): 3 oz × 30 mL = 90 mL
Step 2: Add all the mL values together:
240 + 120 + 90 + 240 + 240 + 150 + 90 = 1,170 mL
Final Answer: 1,170 mL
Correct Answer is A
Explanation
A. Call the health care provider, a blockage is present in the tubing: A sudden decrease in drainage can indicate a blockage in the tubing, which could lead to fluid buildup and infection. The provider should be notified so that interventions can be taken (e.g., irrigation, assessment for clot formation).
B. Remove the drain, a drain is no longer needed: The nurse should not remove the drain without a provider’s order. A decrease in drainage does not necessarily mean the wound has healed.
C. Do nothing as long as the evacuator is compressed. Even if the evacuator is compressed, a sudden decrease in drainage is abnormal and requires further investigation. Ignoring it can lead to complications like hematoma or infection.
D. Chart the results on the intake and output flow sheet. While documenting the change is important, charting alone is not an appropriate intervention. The nurse must also assess for possible causes of the decreased drainage and notify the provider.
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