A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

Use a cuﬀ with a width that is about 60% of the client's arm circumference.

Apply the cuﬀ above the client's antecubital fossa.

Have the client sit with his arm resting above the level of his heart.

Release the pressure on the client's arm 5 to 6 mm per second.

Answer and Explanation

The Correct Answer is A

When checking a client's blood pressure, the nurse should use a cuﬀ with a width that is about 60% of the client's arm circumference. This will help to ensure that the cuﬀ fits properly and provides an accurate reading.

Options b, c, and d are not correct. The cuﬀ should be applied over the client's brachial artery, which is located in the antecubital fossa. The client should sit with their arm resting at the level of their heart, not above it. The pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.

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Correct Answer is B

Explanation

An alternating pressure mattress can help prevent skin breakdown in a client who is immobile by redistributing pressure and reducing the risk of pressure ulcers. This is an appropriate action for the nurse to include in the plan of care for a client who is immobile and has urinary incontinence.

a. An indwelling urinary catheter can increase the risk of infection and should only be used when other methods of managing urinary incontinence are not eﬀective.

c. Cornstarch can absorb moisture and help keep the skin dry, but it is not recommended for use on broken skin or in areas where there is a risk of fungal infection.

d. Repositioning the client every 4 hours may not be frequent enough to prevent skin breakdown. The client should be repositioned at least every 2 hours to reduce the risk of pressure ulcers.

A. "Let's discuss other areas of your partner's care." B. "I understand how you feel because I recently lost a family member myself." C. "It must be very difficult for you to accept your partner's wishes." D. "You should call your partner's provider to change the DNR order."

Correct Answer is C

Explanation

a) This response may seem dismissive of the partner’s immediate concern about the DNR order and does not directly address their request.
b) While this response attempts to establish a connection through shared experience, it may shift the focus away from the partner's feelings and can come off as self-centered. It may also invalidate the partner's unique experience of loss.
c) This response acknowledges the emotional distress and difficulty the partner is experiencing while validating their feelings. It shows empathy and understanding, which can help build rapport and encourage further communication about the situation.

d)This response is inappropriate because it does not respect the existing DNR order and could create confusion or frustration for the partner. Additionally, changing a DNR order requires specific processes and discussions with the healthcare team.

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A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is speaking with the partner of a client who is unconscious and has a do-not-resuscitate (DNR) order in place. The partner requests that CPR be performed if necessary. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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