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.

Answer and Explanation

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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Correct Answer is B

Explanation

The correct answer is choice B. Isolate the client from staff who are pregnant. Choice A rationale: Aspirin should not be administered to children or adolescents with viral infections like rubella due to the risk of Reye's syndrome, a potentially fatal condition that causes liver and brain damage. Choice B rationale: Rubella (German measles) is particularly dangerous for pregnant women because it can cause congenital rubella syndrome in the fetus, leading to severe birth defects. Therefore, isolating the client from pregnant staff is crucial to prevent exposure. Choice C rationale: Airborne precautions are not necessary for rubella. Rubella is transmitted through respiratory droplets, so droplet precautions, not airborne precautions, are appropriate. Choice D rationale: Koplik spots are associated with measles (rubeola), not rubella. Therefore, monitoring for Koplik spots is not relevant for a client with rubella.

A. Allow the client to choose among a variety of activities each day. B. Give the client one simple direction at a time. C. Reinforce orientation to time, place, and person. D. Establish eye contact when communicating with the client. E. Refute the client’s delusions using logic.

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

Explanation

The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.

These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.

Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.

The nurse should provide a structured and consistent daily routine for the client.

Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.

The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.

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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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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?