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 C
Explanation
A. Explain the techniques of esophageal speech.Esophageal speech is one method of communication but is learned later through speech therapy. Not the immediate priority.
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.After surgery, the client will not be able to speak initially. Knowing if the client can read and write allows the nurse to provide a communication method (such as writing or using a communication board) to meet immediate needs, especially related to airway, pain, and care.
D. Review the use of an artificial larynx with the client.An electrolarynx is an option but is introduced later in recovery. It is not the immediate concern before surgery.
Correct Answer is B
Explanation
Crackles in the lungs indicate that the client is experiencing fluid overload. When there is an excess of fluid in the body, it can accumulate in the lungs and cause crackles. The other
a. Fever is not a sign of fluid overload.
c. Bradycardia (a slow heart rate) is not a sign of fluid overload.
d. Flattened neck veins are not a sign of fluid overload; distended neck veins may be a sign of fluid overload.
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