A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

The site where the blood pressure was obtained.

Interventions implemented in response to a client's blood pressure.

A client's position when the blood pressure was obtained.

The frequency in which a blood pressure is taken.

A client's response to interventions implemented.

Answer and Explanation

Correct Answer : A,B,C,D,E

A.   The site where the blood pressure was obtained is important to document because blood pressure measurements can differ significantly between different parts of the body (e.g., arm versus thigh). Documenting the site ensures that future measurements can be compared appropriately.
B.   Interventions implemented in response to a client's blood pressure need documentation to track what actions were taken and whether these actions had the intended effect on the patient's health status. This helps in assessing the efficacy of interventions.
C.   A client's position when the blood pressure was obtained affects the readings; measurements might differ when taken in positions such as lying, sitting, or

standing. Accurate documentation of position helps in ensuring that readings are interpreted correctly.
D.   The frequency in which a blood pressure is taken provides context for understanding how the patient’s blood pressure is trending over time, which is critical for ongoing management and therapeutic decisions, especially in unstable or critical patients.
E.   A client's response to interventions implemented should be documented to evaluate whether the treatment plan needs adjustments and to understand how the patient is coping with the treatment. This documentation is crucial for patient safety and care continuity.

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Correct Answer is A

Explanation

A: This helps reduce body temperature by increasing heat loss through evaporation and radiation. Removing layers allows the body’s natural cooling mechanisms to function more effectively.
B: This would be inappropriate because adequate hydration is crucial for a febrile patient to help regulate body temperature and prevent dehydration.
C: This would be counterproductive as it would add heat to the body instead of helping to lower the body temperature.
D: Increasing the room temperature would worsen the situation by making the environment warmer, which would hinder the body's ability to cool down naturally.

A. Subjective B. Objective and measurable C. Reported by the patient D. Hidden

Correct Answer is B

Explanation

A: Subjective information refers to what the patient experiences and reports, not what is sensed by the observer.
B: Objective signs are those that can be observed and measured by someone other than the patient, such as visual inspections, palpations, and auditory cues.
C: Reported by the patient would be subjective data, opposite of what is sensed and recorded by healthcare providers.
D: Hidden signs would imply they are not readily observable, which contradicts the use of senses to identify them.

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A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

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