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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Opioid toxicity can cause difficulties with breathing and an opioid overdose can lead to death1. A respiratory rate of 10/min is considered low and could be a sign of opioid toxicity.

A. A client who has haemorrhoids B. A client who had recent oral surgery C. A client who has a coagulation disorder D. A client who is drinking ice water

Correct Answer is A

Explanation

Answer: A

Rationale:

A) A client who has hemorrhoids: An oral temperature is appropriate for this client as there are no contraindications for using the oral route. Hemorrhoids do not affect the accuracy or safety of oral temperature measurement.

B) A client who had recent oral surgery: Oral temperature measurement should be avoided for this client as it may cause discomfort or disrupt the healing process. Alternative routes, such as tympanic or axillary, are more appropriate.

C) A client who has a coagulation disorder: Oral temperature measurement might be risky in clients with coagulation disorders due to the potential for trauma or bleeding from the oral mucosa. A non-invasive method is preferable for safety.

D) A client who is drinking ice water: Drinking ice water can temporarily lower the temperature in the oral cavity, leading to inaccurate readings. The nurse should wait 15–30 minutes before measuring an oral temperature.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

Explanation

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