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 B

Explanation

Turning the client to the side can help prevent aspiration while performing oral care on an unconscious patient.

A. The client’s systolic blood pressure decreases from 110 mm Hg to 105 mm Hg. B. The client reports nausea. C. The client’s heart rate increases from 100/min to 108/min. D. The client reports dizziness.

Correct Answer is A

Explanation

Postural hypotension, also known as orthostatic hypotension, is a form of low blood pressure that occurs when standing up from a sitting or lying down position 1. An eﬀective intervention for postural hypotension would be one that helps to prevent a significant drop in blood pressure when the client changes position. A small decrease in systolic blood pressure, such as from 110 mm Hg to 105 mm Hg, would indicate that the intervention is eﬀective in preventing a larger drop in blood pressure.

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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

A nurse is performing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has postural hypotension. The nurse assists the client gradually from a lying down to standing position. The nurse should identify that which of the following findings indicates the intervention is eﬀective?

Correct Answer is A

Explanation

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