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.
Use the palpatory method to determine blood pressure.
Place the arm above the level of the client’s heart.
Deflate the cuff quickly.
The Correct Answer is B
The systolic pressure is estimated by noting the pressure at which the pulse disappears and reappears. The diastolic pressure is not measured by this method, but it can be useful when the sounds are difficult to hear.
Choice A is wrong because applying the largest cuff available can result in a falsely low reading. The cuff size should be appropriate for the client’s arm circumference.
Choice C is wrong because placing the arm above the level of the client’s heart can also cause a falsely low reading. The arm should be at the level of the heart for an accurate measurement.
Choice D is wrong because deflating the cuff quickly can lead to missing or skipping sounds, resulting in an inaccurate reading. The cuff should be deflated slowly and evenly.
Normal ranges for blood pressure vary depending on age, sex, and health conditions, but generally, a systolic pressure below 120 mmHg and a diastolic pressure below 80 mmHg are considered normal for adults.
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Related Questions
Correct Answer is C
Explanation
Banana slices are soft, easy to chew, and can be picked up by the toddler’s fingers, which promotes independence in eating. According to the CDC, foods that toddlers should avoid include:
- Added sugars and no-calorie sweeteners, such as sugar-sweetened and diet drinks
- High-salt foods, such as canned foods, processed meats, frozen dinners, fast food, and junk food
- Unpasteurized juice, milk, yogurt, or cheese
- Foods that may cause choking, such as hard or crunchy foods, sticky foods, stringy cheese, and foods that are not cut up into small pieces
Choice A is wrong because popcorn is a choking hazard for toddlers.
It is hard, crunchy, and can get stuck in the airway. The NHS advises not to give whole nuts and peanuts to children under 5 years old.
Choice B is wrong because grapes are also a choking hazard for toddlers.
They are round, slippery, and can block the airway. The NHS recommends cutting grapes into quarters before giving them to young children.
Choice D is wrong because hot dogs are high in salt and can cause choking if not cut up into small pieces. The Extension warns against giving hot dogs to young toddlers.
Correct Answer is B
Explanation
Choice A reason
Administering naloxone to the newborn is not appropriate. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose in adults. It is not typically used for newborns with neonatal abstinence syndrome. The management of NAS is primarily supportive, and medications may be prescribed to help manage specific withdrawal symptoms, but naloxone is not a standard treatment for NAS.
Choice B reason:
Minimizing noise in the newborn's environment is a crucial action in the plan of care is the correct action to be included. Newborns experiencing NAS can be easily overstimulated, and loud noises can exacerbate their withdrawal symptoms and distress. Creating a calm and quiet environment helps reduce agitation and promotes better sleep and overall comfort.
Choice C reason
Swaddling the newborn with his leg extended is not appropriate in this case. Swaddling can be beneficial for some newborns, but the specific positioning and swaddling techniques should be individualized based on the newborn's needs and preferences. Extending the newborn's legs may not necessarily be the best approach, as it may not provide comfort or address the symptoms associated with NAS.
Choice D reason:
Maintaining eye contact with the newborn during feedings is not appropriate in this case. While maintaining eye contact during feedings is an essential aspect of bonding and promoting parent-newborn attachment, it may not be the primary focus in managing neonatal abstinence syndrome. The plan of care for a newborn with NAS would primarily involve managing withdrawal symptoms, providing comfort measures, and addressing the newborn's unique needs during this challenging period.
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