A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?
Apply the largest cuff available.
Place the arm above the level of the client's heart.
Deflate the cuff quickly.
Use the palpatory method to determine blood pressure.
The Correct Answer is D
A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.
B. Incorrect. To auscultate blood pressure accurately, it's essential to follow proper positioning and technique, which typically involves having the client's arm at heart level. Placing the arm above heart level can lead to falsely lower blood pressure readings.
C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.
D. Using the palpatory method, the nurse can feel for the radial pulse while slowly deflating the blood pressure cuff. This helps estimate the systolic blood pressure when Korotkoff sounds are challenging to hear. It provides a rough estimate until clear sounds can be heard and ensures accurate blood pressure measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Headache is a common adverse effect of disulfiram when alcohol is consumed. It is part of the adverse reaction created by the drug to deter individuals from drinking. While headache is a known symptom, tinnitus is a more specific and distinctive adverse effect associated with disulfiram use.
Choice B rationale:
Hypertension is not a common adverse effect of disulfiram. Disulfiram does not directly impact blood pressure. Its primary action is to cause an adverse reaction when alcohol is consumed.
Choice C rationale:
Tinnitus (ringing in the ears) is a known adverse effect of disulfiram when alcohol is ingested. Disulfiram inhibits the breakdown of acetaldehyde, leading to an accumulation of this toxic substance in the body. Tinnitus is one of the symptoms of this toxic reaction and is a significant concern in individuals taking disulfiram for alcohol use disorder.
Choice D rationale:
Insomnia is not a common adverse effect of disulfiram. Disulfiram works by creating an unpleasant reaction when alcohol is consumed, which deters individuals from drinking. This reaction does not typically manifest as insomnia.
Correct Answer is C
Explanation
Choice C rationale:
Avoiding consuming foods containing chocolate is important for individuals with gastroesophageal reflux disease (GERD) Chocolate contains substances that can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus, worsening GERD symptoms. Therefore, the nurse should include this information in the discharge teaching to help the client manage GERD effectively.
Choice A rationale:
Taking antacids that contain mint for heartburn is not recommended. Mint can relax the lower esophageal sphincter, similar to chocolate, potentially worsening GERD symptoms. Therefore, clients with GERD should avoid mint-containing products.
Choice B rationale:
Increasing dietary intake of citrus fruits is not advisable for individuals with GERD. Citrus fruits are acidic and can irritate the esophagus, leading to increased reflux symptoms. Clients with GERD should limit or avoid citrus fruits in their diet.
Choice D rationale:
Lying down for 30 minutes after eating a meal is not a recommended practice for individuals with GERD. Instead, clients with GERD should remain upright for at least 2-3 hours after eating to reduce the risk of reflux. Lying down shortly after a meal can worsen symptoms by allowing stomach acid to flow back into the esophagus more easily.
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