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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Hold her breath for at least 10 seconds. Diaphragmatic breathing focuses on slow, deep breaths to promote lung expansion and oxygenation. Holding the breath is not part of this technique and may increase discomfort.

B. Place her hands on the sides of her rib cage. While hand placement is encouraged, the correct position is on the abdomen (below the rib cage), not the sides. This helps the client feel the diaphragm expanding.

C. Exhale forcefully through the nose. Exhalation should be slow and controlled through the mouth, not forceful through the nose, to prevent airway irritation.

D. Inhale slowly and evenly through her nose. The correct technique for diaphragmatic breathing is to inhale deeply through the nose while the abdomen expands. This promotes lung expansion and prevents atelectasis postoperatively.

A. Tell the client to blow his/her nose gently before the instillation of the drops. B. Assist the client to a side-lying position. C. Hold the dropper 2 cm (1 inch) above the nares D. Instruct the client to stay in the same position for 2 minutes.

Correct Answer is A

Explanation

A. Tell the client to blow his/her nose gently before the instillation of the drops. Blowing the nose clears the nasal passages, allowing the medication to reach the mucosa effectively.

B. Assist the client to a side-lying position. The correct position is head tilted backward (supine with neck hyperextended) or head tilted slightly to the side to ensure proper absorption. A side-lying position is not appropriate for nasal drops.

C. Hold the dropper 2 cm (1 inch) above the nares. The dropper should be placed just inside the nostril without touching it to prevent contamination. Holding it too high may cause the drops to miss the nasal mucosa.

D. Instruct the client to stay in the same position for 2 minutes. Remaining in position for at least 5 minutes allows the medication to be absorbed without draining out of the nasal cavity.

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

Nursing Test Bank

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