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
A. Incorrect. Family history of malignant hypertension is not a contraindication for alteplase.
B. Incorrect. COPD itself is not a contraindication for alteplase. While it can complicate overall management, it does not increase the immediate risk of bleeding associated with thrombolytics.
C. Correct. Recent surgery, especially orthopedic surgery like hip arthroplasty, is a contraindication for thrombolytic therapy due to the increased risk of bleeding and hematoma formation at the surgical site.
D. Incorrect. Acute renal failure from six months ago is not a contraindication for alteplase.
Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"C"},"C":{"answers":"A,C"},"D":{"answers":"A,C"},"E":{"answers":"C"}}
Explanation
A. Weight loss - Consistent with: Ulcerative colitis, Crohn's disease
B. Steatorrhea - Consistent with: Crohn's disease
C. Anemia - Consistent with: Ulcerative colitis, Crohn's disease
D. Diarrhea - Consistent with: Ulcerative colitis, Crohn's disease
E. Fever - Consistent with: Crohn's disease
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