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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is that the nurse should place the base of a vibrating tuning fork on the top of the client's head when performing Weber's test. Weber's test is a screening test for hearing that can detect unilateral (one-sided. conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear hearing loss)².

Options b, c and d are not correct actions for performing Weber's test. Counting how many seconds a client can hear a tuning fork after it has been struck, placing the base of a vibrating tuning fork on the client's mastoid process and moving a vibrating tuning fork in front of the client's ear canals one after the other are not part of Weber's test.

A. Position the client 3.3 m (10 feet) away from the chart. B. Document the largest line the client can read on the chart. C. Instruct the client to begin the assessment with both eyes open. D. Begin by testing the client while they are wearing glasses.

Correct Answer is D

Explanation

The correct answer is choice d. Begin by testing the client while they are wearing glasses. Choice A rationale: Positioning the client 3.3 meters (10 feet) away from the chart is incorrect because the standard distance for the Snellen chart is 20 feet (6 meters). Choice B rationale: Documenting the largest line the client can read on the chart is part of the procedure, but it is not the initial action the nurse should take. The nurse must first ensure the client is wearing their glasses to get an accurate assessment. Choice C rationale: Instructing the client to begin the assessment with both eyes open is incorrect because visual acuity is typically tested one eye at a time, with the other eye covered. Choice D rationale: Beginning by testing the client while they are wearing glasses is correct because it provides the most accurate assessment of the client’s visual acuity in their usual state, ensuring the glasses are effectively correcting their vision

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is testing a client for conduction deafness by performing the Weber's test. Which of the following actions should the nurse take when performing this test?

Correct Answer is A

Explanation

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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