A client has arrived at the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do?
Position the arm so that it is below waist level.
Palpate the radial artery to confirm a pulse is present.
Ask the client to sit quietly in a chair for 5 minutes.
Make sure the arm selected is covered with clothing.
The Correct Answer is C
Choice A Reason:
Positioning the arm below waist level is not recommended when measuring blood pressure. It can result in an inaccurate reading, typically showing a higher blood pressure due to the effects of gravity on the blood column. The arm should be positioned at heart level for an accurate measurement.
Choice B Reason:
While palpating the radial artery to confirm a pulse is present is part of the overall assessment of circulation, it is not a necessary step immediately before measuring blood pressure. The focus should be on ensuring the client is in the correct position and is relaxed to avoid any factors that might artificially alter the blood pressure reading.
Choice C Reason:
Asking the client to sit quietly in a chair for 5 minutes is the correct procedure before measuring blood pressure. This allows the client's heart rate and blood pressure to stabilize, providing a more accurate measurement. Any activity or stress can temporarily raise blood pressure, so this quiet time is crucial.
Choice D Reason:
The arm selected for blood pressure measurement should not be covered with clothing. Clothing can constrict the blood pressure cuff and interfere with the accuracy of the reading. The cuff should be placed on bare skin to ensure it inflates and deflates correctly and that the stethoscope can accurately detect the sounds of the blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice a reason:
Wearing nonslip shoes in the house can prevent falls, which are a common cause of traumatic brain injuries (TBIs) in adolescents. Falls often occur due to slippery surfaces, and nonslip shoes provide better traction, reducing the risk of such accidents.
Choice b reason:
Supervised use of guns by an adult is crucial to prevent accidental shootings, which can result in TBIs or even more severe outcomes. Adolescents may not fully understand the risks associated with handling firearms, and adult supervision ensures that safety measures are followed.
Choice c reason:
The consistent use of seat belts in vehicles is one of the most effective ways to prevent TBIs during car accidents. Seat belts keep occupants from being ejected or hitting the interior of the car, significantly reducing the risk of head injuries.
Choice d reason:
Avoiding risky activities such as snowboarding without proper safety measures can prevent sports-related TBIs. While snowboarding, wearing a helmet and other protective gear is essential to protect the head during falls or collisions.
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Assessing vital signs is crucial for evaluating the client's responses to treatment. Changes in vital signs can indicate whether the body is responding positively or negatively to a treatment, allowing healthcare providers to adjust care plans accordingly. For example, a decrease in fever after administering antipyretics would suggest the treatment is effective.
Choice B Reason:
While carrying out orders from the healthcare provider is a responsibility of the nurse, it is not the primary reason for assessing vital signs. Vital signs are assessed to inform clinical decisions, not solely to fulfill orders. Therefore, this choice is not correct in the context of the importance of vital sign assessment.
Choice C Reason:
Monitoring risks for alterations in health is another key reason for assessing vital signs. Vital signs can serve as early indicators of health issues, such as the onset of an infection indicated by a rising temperature or cardiovascular problems suggested by changes in blood pressure or heart rate.
Choice D Reason:
Establishing a baseline is essential when assessing vital signs. It provides a reference point for future comparisons, which is important for detecting any deviations from the client's normal range. This helps in identifying potential health issues early and monitoring the progression of known conditions.
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