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 ["A","B","D","E"]

Explanation

The nurse should stop the transfusion, place the client in high-Fowler's position, obtain a prescription for a diuretic, and administer oxygen to the client. These actions can help manage the symptoms of transfusion- associated circulatory overload (TACO), which can occur when a client receives too much ﬂuid too quickly during a blood transfusion.

c. Administering epinephrine is not an appropriate action for managing TACO. Epinephrine is used to treat anaphylaxis, which is a diﬀerent type of transfusion reaction.

A. Explain the techniques of esophageal speech. B. Schedule a support session for the client. C. Determine the client's reading ability. D. Review the use of an artificial larynx with the client.

Correct Answer is D

Explanation

A. Explain the techniques of esophageal speech.Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.

B. Schedule a support session for the client.While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.

C. Determine the client's reading ability.This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.

D. Review the use of an artificial larynx with the client.This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.

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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 assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

Correct Answer is D

Explanation

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