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 D

Explanation

The correct answer is choice d. Begin by testing the client while they are wearing glasses. Choice A rationale: Positioning the client 3.3 meters (10 feet) away from the chart is incorrect because the standard distance for the Snellen chart is 20 feet (6 meters). Choice B rationale: Documenting the largest line the client can read on the chart is part of the procedure, but it is not the initial action the nurse should take. The nurse must first ensure the client is wearing their glasses to get an accurate assessment. Choice C rationale: Instructing the client to begin the assessment with both eyes open is incorrect because visual acuity is typically tested one eye at a time, with the other eye covered. Choice D rationale: Beginning by testing the client while they are wearing glasses is correct because it provides the most accurate assessment of the client’s visual acuity in their usual state, ensuring the glasses are effectively correcting their vision

A. Encourage the client to make choices regarding hygiene. B. Oﬀer the client sips of a citrus ﬂavored soda. C. Position the client supine in bed. D. Suction the client's airway every hour.

Correct Answer is A

Explanation

When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.

Option b is incorrect because oﬀering the client sips of a citrus ﬂavored soda may not be appropriate for all clients and should be based on individual preferences and needs.

Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.

Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.

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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

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