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 D

Explanation

A.Induration after a Mantoux test is a common response and does not necessarily require follow-up care.
B.A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L).
C.Sodium phosphate is commonly used for bowel preparation before procedures like colonoscopy.
D.Correct. An INR of 1.8 for a client on warfarin is below the therapeutic range (usually 2.0- 3.0 for most indications), indicating that the client's blood may not be adequately anticoagulated. This requires follow-up to adjust the warfarin dose.

A. "You don't have to go through with the treatment." B. "Your doctor wouldn't have ordered this treatment unless it was necessary." C. "Most people who have this procedure feel better following the treatment." D. "It's okay to be nervous before this treatment."

Correct Answer is A

Explanation

A. Correct. Informed consent means the client has the right to refuse treatment even after giving initial consent. The nurse should respect the client's autonomy and decision.

B. Incorrect. This statement does not respect the client's right to make decisions about her treatment.

C. Incorrect. While this statement might be true for some individuals, it does not address the client's current hesitation and does not respect her autonomy.

D. Incorrect. This statement does not address the client's expressed hesitation about the treatment.

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