A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuff to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)
Palpate the brachial pulse site.
Discontinue palpation of the brachial pulse.
Inflate the blood pressure cuff to 30 mm Hg beyond where the brachial pulse was last felt.
Deflate the blood pressure cuff slowly until the brachial pulse is detected.
The Correct Answer is A, C, B, D
First, the nurse should palpate the brachial pulse site to locate the artery. Next, the nurse should inflate the blood pressure cuff to 30 mm Hg beyond where the brachial pulse was last felt. The nurse should then discontinue palpation of the brachial pulse and deflate the blood pressure cuff slowly until the brachial pulse is detected. This is the point at which the systolic blood pressure can be read.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is that discussing the client's transfer to a long-term care facility with a nurse from another unit is a violation of HIPA
A. HIPAA regulations require that healthcare providers protect the privacy of their clients' personal health information (PHI) and only share it with authorized individuals on a need- to-know basis.
Options a, b and d are not violations of HIPAA. Faxing medical information to the client's provider's office, teaching the client discharge instructions with his partner present and giving a telephone report to a surgical nurse when sending the client to the surgical suite are all acceptable practices under HIPAA regulations.
Correct Answer is D
Explanation
The nurse should ask a second nurse to record her signature when wasting any unused portion of the controlled substance. This is a standard procedure for the safe handling and documentation of controlled substances.
a. The nurse should report any discrepancy in the count total of the controlled substance before administration, not after.
b. The wasted portion of the controlled substance should be disposed of according to facility policy, which may not involve placing it in a sharps container.
c. The count total of the controlled substance should be verified before removing the amount needed, not after.
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