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
Parenteral nutrition (PN) with high concentrations of dextrose, such as 20%, requires a central venous line for administration to prevent damage to peripheral veins. Therefore, preparing the client for a central venous line is an appropriate action to include in the plan of care.
a. The PN infusion bag should be changed every 24 hours to reduce the risk of infection.
d. Blood glucose levels should be monitored regularly, but not necessarily daily, as PN can affect blood glucose levels.
c. PN and fat emulsions can be administered together in a single infusion.
Correct Answer is D, B, A, C
Explanation
When caring for a client who is nauseated and unable to eat after taking an antibiotic, the nurse should first identify possible nursing interventions that address the client's nausea. The nurse should then review the potential benefits and consequences of each intervention. The nurse should determine the probability of intervention-related complications. Finally, the nurse should select an intervention that provides the greatest benefit and least risk to the client.
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