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.

Answer and Explanation

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.

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Correct Answer is ["A","C","D"]

Explanation

A. Correct. Reinforcing orientation to time, place, and person helps ground the client in reality, even if their memory is impaired.

B. Incorrect. While it's important to provide the client with some choices, too many options can be overwhelming and confusing.

C. Correct. Providing one simple direction at a time helps prevent confusion and frustration for clients with dementia.

D. Correct. Establishing eye contact while communicating can enhance the client's focus and understanding.

E. Incorrect. It's generally not effective to try to refute a client's delusions using logic.

Redirecting or validating their feelings might be more appropriate.

A. "Store unused patches in the refrigerator.” B. "Apply the patch prior to traveling.” C. "Place the patch on your upper arm.” D. "Replace a dislodged patch onto the same location.”

Correct Answer is B

Explanation

Choice A rationale:

Storing unused patches in the refrigerator is not necessary for transdermal scopolamine patches. Refrigeration is not a requirement for their storage.

Choice B rationale:

Applying the patch prior to traveling is the correct choice. Transdermal scopolamine patches are used to prevent motion sickness. Applying the patch before the journey allows the medication to be absorbed before exposure to motion, ensuring its effectiveness during travel.

Choice C rationale:

Placing the patch on the upper arm is a specific and correct instruction for applying transdermal scopolamine patches. The patch should be placed on a clean, dry, and hairless area of the skin, preferably behind the ear or on the upper arm.

Choice D rationale:

Replacing a dislodged patch onto the same location is incorrect. If the patch becomes dislodged, it should be replaced with a new patch on a different, clean, and dry area of the skin. Reapplying a dislodged patch to the same spot may result in uneven absorption and reduced effectiveness.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is B

Explanation

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