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 B

Explanation

After moving clients to a safe location, the next action the nurse should take is to pull the fire alarm. This will alert others in the building to the presence of a fire and activate the building's fire suppression systems.

Options a, c, and d are not the next actions the nurse should take. Using an extinguisher to put out the fire may be appropriate if the nurse has been trained to do so and if it is safe to do so. Closing the doors to client rooms can help to contain the spread of smoke and fire, but it is not the next action the nurse should take. Turning oﬀ electrical equipment in the room may help to prevent further ignition sources, but it is not the next action the nurse should take.

A. Decreased sense of balance B. Nighttime urinary incontinence C. Heightened sense of pain D. Increased nighttime sleeping

Correct Answer is A

Explanation

As individuals age, it is common for them to experience a decreased sense of balance. This can be attributed to age-related changes in the musculoskeletal system, sensory perception, and coordination. The inner ear, which plays a vital role in maintaining balance, undergoes natural degenerative changes over time. Additionally, age-related decline in muscle strength and ﬂexibility can contribute to difficulties in maintaining balance. Therefore, a nurse assessing an older adult client should expect a decreased sense of balance as a common finding.

Nighttime urinary incontinence: While nighttime urinary incontinence can occur in some older adults, it is not a universal finding. It is important to avoid making assumptions or generalizations about older adults experiencing urinary incontinence. Each individual's urinary function can vary, and incontinence can be inﬂuenced by various factors such as overall health, bladder capacity, medication use, and underlying medical conditions.
Heightened sense of pain: Older adults may experience changes in pain perception due to age-related physiological changes and medical conditions. However, it is not a predictable or expected finding for all older adult clients. Pain perception can vary among individuals based on their overall health, chronic conditions, and individual pain thresholds. Therefore, while some older adults may experience heightened pain sensitivity, it is not a universal expectation.
Increased nighttime sleeping: Sleep patterns can change with age, and older adults may experience alterations in their sleep-wake cycles. However, increased nighttime sleeping is not a definitive finding that applies to all older adult clients. Sleep patterns can vary greatly among individuals, and some older adults may experience decreased sleep duration or disrupted sleep rather than increased nighttime sleeping.

In summary, the nurse should expect a decreased sense of balance as a common finding when assessing an older adult client. It is important to approach each individual as unique and recognize that other findings such as nighttime urinary incontinence, heightened sense of pain, or increased nighttime sleeping may or may not be present, as they can vary among older adults based on individual factors.

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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 enters a client's room and discovers a smoldering fire in the drapes. After moving clients to a safe location, which of the following actions should the nurse take next?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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