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 B
Explanation
A. Incorrect. Covering the adolescent with a thermal blanket may worsen hyperthermia.
B. Correct. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
C. Incorrect. Submerging the feet in ice water is not recommended due to the risk of causing shock.
D. Incorrect. Administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
Explanation
Serotonin syndrome: This is a potentially life-threatening condition caused by an excess of serotonin in the brain. It can occur when there is an increase in the dose of an SSRI or when a new SSRI is introduced, particularly if the client has recently been on another SSRI, as in this case where fluoxetine was switched to paroxetine.
Selective serotonin reuptake inhibitors (SSRIs): Both fluoxetine and paroxetine are SSRIs. The risk of serotonin syndrome increases with changes or increases in the dosage of SSRIs due to the potential for excessive serotonin levels.
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