A nurse is preparing to obtain a blood pressure reading from a school-age child. Which of the following actions should the nurse take?
Record the diastolic value as the first Korotkoff sound (K1).
Release the cuff pressure at a rate of about 5 mm Hg/second.
Position the child's arm at the level of the heart.
Select a cuff with a bladder size that is approximately 20% of the child's upper arm circumference.
The Correct Answer is C
Rationale:
A) The diastolic value is recorded as the disappearance of Korotkoff sounds (K5), not the first sound (K1).
B) The cuff pressure should be released at a rate of 2-3 mm Hg/second, not 5 mm Hg/second.
C) Positioning the child's arm at the level of the heart ensures an accurate blood pressure measurement.
D) The cuff bladder size should be approximately 40% of the child's upper arm circumference, not 20%.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A) Watching cartoons with peers may increase the risk of transmitting varicella- zoster virus to other children who may not be immune, as well as expose the child to potential infections from other sick children.
B) Pulling a wagon of stuffed animals in the hallway is too strenuous for a child with pneumonia.
C) Writing a letter to send to a friend may be an appropriate activity for a child with pneumonia, but it involves sitting still for an extended period, which may not be as beneficial as a more physically engaging activity.
D) Playing an alphabet flashcard game with the parent is appropriate for a 4-year-old child's cognitive development and does not require physical exertion or exposure to other children who might be susceptible to varicella zoster infection.
Correct Answer is C
Explanation
Rationale:
A) Peanut butter is not a rapidly absorbed source of glucose and may not be appropriate for treating hypoglycemia.
B) While rechecking the child's blood glucose level is important, immediate treatment should be initiated for symptomatic hypoglycemia.
C) Administering a rapidly absorbed source of sugar, such as 1 tablespoon of sugar or honey, is the priority intervention for treating hypoglycemia in a conscious child.
D) Documenting the incident is important but should not delay the administration of treatment for hypoglycemia.
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