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. Position the client 3.3 m (10 feet) away from the chart. B. Document the largest line the client can read on the chart. C. Instruct the client to begin the assessment with both eyes open. D. Begin by testing the client while they are wearing glasses.

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

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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 assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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