A nurse is assessing a client's blood pressure using a manual sphygmomanometer and a stethoscope. What action should the nurse take to obtain an accurate blood pressure reading?

Inflate the cuff to 20 mmHg above the estimated systolic pressure.

Deflate the cuff at a rate of 10-20 mmHg per second.

Place the bell of the stethoscope over the brachial artery.

Palpate the radial artery while auscultating for Korotkoff sounds.

Answer and Explanation

The Correct Answer is C

Answer: c. Place the bell of the stethoscope over the brachial artery.

Explanation: To obtain an accurate blood pressure reading, the nurse should place the bell of the stethoscope over the brachial artery, which is located in the antecubital fossa.

a. Inflating the cuff to 20 mmHg above the estimated systolic pressure may be appropriate for initial inflation, but the cuff should be inflated further until the radial pulse disappears, and then slowly deflated to obtain accurate readings.

b. Deflating the cuff at a rate of 2-3 mmHg per second is recommended to obtain accurate blood pressure readings.

d. Palpating the radial artery while auscultating for Korotkoff sounds is not necessary for accurate blood pressure measurement and may interfere with accurate assessment.

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Correct Answer is D

Explanation

Explanation: A respiratory rate of 8 breaths per minute is significantly below the normal range (12-20 breaths per minute), indicating potential respiratory distress. The nurse should perform a thorough respiratory assessment to gather more information and determine appropriate interventions.

a. Administering oxygen may be necessary, but the nurse should first assess the client's respiratory status before initiating any interventions.

b. Placing the client in a supine position is not indicated and may worsen respiratory distress in some situations.

c. Reassessing after 1 hour is not appropriate when a client is experiencing abnormal vital signs; immediate action is needed.

A. Insert the thermometer into the rectum for accurate measurement. B. Place the thermometer in the client's axilla and secure with a towel. C. Swipe the thermometer gently across the client's forehead. D. Hold the thermometer under the client's tongue for 30 seconds.

Correct Answer is C

Explanation

Answer: c. Swipe the thermometer gently across the client's forehead.

Explanation: Temporal artery thermometers are used by swiping the thermometer gently across the client's forehead. The device measures the temperature of the temporal artery, which correlates with core body temperature.

a. Inserting the thermometer into the rectum is not the appropriate method for using a temporal artery thermometer.

b. Placing the thermometer in the axilla is appropriate for axillary temperature measurement but not for temporal artery thermometers.

d. Holding the thermometer under the tongue is appropriate for oral temperature measurement but not for temporal artery thermometers.

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A nurse is assessing a client's blood pressure using a manual sphygmomanometer and a stethoscope. What action should the nurse take to obtain an accurate blood pressure reading?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's respiratory rate and finds it to be 8 breaths per minute. What action should the nurse take first?

Correct Answer is D

Explanation

A nurse is assessing a client's body temperature using a temporal artery thermometer. How should the nurse use the temporal artery thermometer?

Correct Answer is C

Explanation

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A nurse is assessing a client's blood pressure using a manual sphygmomanometer and a stethoscope. What action should the nurse take to obtain an accurate blood pressure reading?