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 B
Explanation
Answer: B. A client who is unconscious.
A. A client who has a spinal cord injury.
While a spinal cord injury is serious and requires close monitoring, this condition does not immediately indicate that the client is unstable or at risk for life-threatening complications compared to an unconscious client. However, if there were signs of respiratory compromise or neurogenic shock, this client could be prioritized higher.
B. A client who is unconscious.
An unconscious client should be seen first because their condition may indicate a critical issue such as impaired airway, breathing, or circulation (ABC). Immediate assessment is needed to ensure the airway is clear, breathing is adequate, and circulation is stable, as these are life-threatening concerns.
C. A client who has peripheral vascular disease.
Clients with peripheral vascular disease (PVD) typically have chronic issues related to circulation in the limbs, which can cause pain and discomfort but are not usually immediately life-threatening. While important, this client is not the top priority compared to an unconscious client.
D. A client who has a new ankle sprain.
A new ankle sprain is painful and requires treatment, but it is not life-threatening. The nurse should address this client after ensuring the more urgent needs of other clients are met, such as the unconscious client who may require immediate interventions to preserve life.
Correct Answer is D
Explanation
The nurse should plan to use warm water to wash the client’s feet as part of proper foot care. Warm water can help soften the skin and nails, making it easier to clean and trim the nails. It is also important to avoid soaking the feet, as this can dry out the skin and increase the risk of infection.
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