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 D
Explanation
A. Incorrect. Providing oral hygiene care is important but not the first priority after a client has vomited
B. Incorrect. While administering an antiemetic medication might be considered, providing oral hygiene care to the client is the immediate priority.
C. Incorrect. Replacing the NG tube is not typically the first action to take after a client vomits. Addressing oral hygiene and assessing the client's condition comes first.
D. Correct. Evaluating the functioning of the suction device is important as it helps to prevent aspiration of contents.
Correct Answer is ["A","D","E"]
No explanation
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