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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When planning an educational conference about informed consent, the nurse should include information about the potential risks of the procedure. Informed consent is a process in which the client is provided with information about a medical procedure or treatment, including its potential risks and benefits, so that they can make an informed decision about whether to proceed.
Option a is incorrect because after signing the informed consent, the client still has the right to refuse the procedure.
Option c is incorrect because it is not the nurse's responsibility to explain the procedure when obtaining informed consent; this is typically done by the healthcare provider performing the procedure.
Option d is incorrect because a nursing student cannot witness an informed consent; only a licensed healthcare professional can do so.
Correct Answer is A
Explanation
The correct answer is that the nurse should place the base of a vibrating tuning fork on the top of the client's head when performing Weber's test. Weber's test is a screening test for hearing that can detect unilateral (one-sided. conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear hearing loss)².
Options b, c and d are not correct actions for performing Weber's test. Counting how many seconds a client can hear a tuning fork after it has been struck, placing the base of a vibrating tuning fork on the client's mastoid process and moving a vibrating tuning fork in front of the client's ear canals one after the other are not part of Weber's test.
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