A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?
Select a cuff that covers 50% of the client’s upper arm.
Place the blood pressure cuff 5 cm (2 in) above the client’s antecubital space.
Elevate the client’s arm above the level of the heart.
Align the artery indicator on the blood pressure cuff with the client’s brachial artery.
The Correct Answer is D
When taking an electronic blood pressure measurement, it is important to properly position the cuff on the client’s arm. The artery indicator on the blood pressure cuff should be aligned with the client’s brachial artery1. It is also important to select a cuff that fits properly and to have the client sit comfortably with their back supported and feet flat on the ground2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer: D. The client grimaces when they move.
Rationale:
A) The client rates their pain as an 8 on a scale of 0 to 10:
Pain ratings provided by the client are subjective and reflect their personal experience and perception of pain. While important for assessing pain severity, this rating is based on the client's personal report rather than observable evidence.
B) The client states the pain is located on their abdomen:
The location of pain, as reported by the client, is subjective information. It is based on the client's personal experience and cannot be objectively measured or observed by the nurse.
C) The client reports a burning sensation:
Describing the sensation of pain, such as a burning feeling, is a subjective experience. This description provides valuable information about the nature of the pain but does not serve as an objective indicator.
D) The client grimaces when they move:
Observing a grimace is an objective indicator of pain. It is a visible, physical response that the nurse can see and document, indicating that the client is experiencing discomfort or pain. Objective indicators are observable signs that can be noted by healthcare providers.
Correct Answer is C
Explanation
A high white blood cell (WBC) count usually indicates an increase in the production of white blood cells to fight an infection
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