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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Free Nursing Study Resources

Correct Answer is C

Explanation

Answer: C. Place a surgical mask on the client when they leave their room.

Rationale:

A) Wear a surgical mask when within 0.6 m (2 ft) of the client.
While it is necessary to wear a surgical mask when in close proximity to a client on droplet precautions, the distance specified (0.6 m or 2 ft) is less than the standard recommended distance of 1 meter (3 feet). Therefore, this option is not fully aligned with best practices.

B) Move the client to a positive airflow room.
Positive airflow rooms are typically used for clients with immunosuppression or those who need protection from airborne pathogens, not for those on droplet precautions. This action is not appropriate for a client requiring droplet precautions.

C) Place a surgical mask on the client when they leave their room.
This action is appropriate and essential to minimize the risk of transmission of infectious agents to others when the client is moving outside their isolation area. The client wearing a mask is a key part of droplet precautions.

D) Remove fresh flowers from the client’s room.
While it may be necessary to remove fresh flowers in certain cases (such as for neutropenic clients), this is not specifically related to droplet precautions. Droplet precautions focus primarily on respiratory secretions and do not directly involve the presence of flowers.

A. Report of dizziness B. History of cigarete smoking C. Hypoglycaemia D. Temperature of 39°C (102°F)

Correct Answer is A

Explanation

A heart rate of 56/min is considered bradycardia, which is defined as a heart rate slower than 60 beats per minute 1. Bradycardia can prevent the brain and other organs from getting enough oxygen, possibly causing symptoms such as dizziness or light-headedness.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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