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 C

Explanation

A. Constipation is a potential side effect of morphine, but it is not the priority concern in this scenario.
B. Euphoria is a potential side effect of morphine but is not as immediately concerning as bradypnea.
C. Correct. Bradypnea (slow breathing) is a potential adverse effect of morphine and can lead to respiratory depression, which is a serious concern.
D. Sedation is an expected side effect of morphine, but the priority concern is the possibility of respiratory depression.

A. Administer biological response modifiers to prevent infection. B. Take a hot shower in the morning to decrease stiffness. C. Cluster physical activities during the day. D. Apply cold packs directly on the skin of the affected joints.

Correct Answer is B

Explanation

A. Biological response modifiers are medications used to treat autoimmune diseases like rheumatoid arthritis, not to prevent infection.

B. Taking a hot shower in the morningcan help decrease stiffness and improve joint mobility for people with rheumatoid arthritis.

C. Clustering physical activities during the day can cause fatigue and joint stress for people with rheumatoid arthritis. It is better to pace activities throughout the day and take frequent breaks to rest the joints.

D. Cold packs can help reduce inflammation and pain, but they should be applied with a cloth barrier to protect the skin from direct contact.

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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?

Nursing Test Bank

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