A nurse is providing teaching about blood pressure measurement to a client who has hypertension. Which of the following instructions should the nurse include?
Use an electronic device.
Inflate the cuff to 140/90 mmHg.
Place the cuff on the upper arm.
Measure blood pressure after exercise.
The Correct Answer is C
Choice A reason: Using an electronic device is not a reliable method for measuring blood pressure because it may give inaccurate readings due to movement, noise, or battery issues. An electronic device should be calibrated regularly and compared with a manual device.
Choice B reason: Inflating the cuff to 140/90 mmHg is not a correct procedure for measuring blood pressure because it may cause discomfort and false readings. The cuff should be inflated to about 20 to 30 mmHg above the expected systolic pressure or until the pulse disappears.
Choice C reason: Placing the cuff on the upper arm is a correct procedure for measuring blood pressure because it ensures that the cuff is at the same level as the heart and that the brachial artery is compressed. The cuff should be snug and fit around 80% of the arm circumference.
Choice D reason: Measuring blood pressure after exercise is not a good time for measuring blood pressure because it may reflect a temporary increase due to physical activity. Blood pressure should be measured after resting for at least 5 minutes in a quiet and comfortable environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The client's creatinine level of 1.0 mg/dL is within the normal range (0.6-1.2), but it does not indicate the effectiveness of the treatment for benign prostatic hyperplasia. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. High creatinine levels can indicate kidney damage or impaired renal function.
Choice B reason: The client's urine output of 35 mL/hr is below the normal range (40-60), and it indicates the need for further assessment. Low urine output can indicate dehydration, urinary retention, or kidney failure.
Choice C reason: The client's stool consistency and color are not related to the treatment for benign prostatic hyperplasia. Soft, brown stool is normal and does not indicate any problem with the digestive system.
Choice D reason: The client's ability to urinate without straining indicates that the treatment for benign prostatic hyperplasia has been effective. Benign prostatic hyperplasia is a condition in which the prostate gland enlarges and compresses the urethra, causing difficulty in urination. Treatment options include medication, surgery, or minimally invasive procedures to reduce the size of the prostate and relieve urinary obstruction.
Correct Answer is B
Explanation
Choice A reason: Telling the client to lie down after eating can increase the risk of aspiration pneumonia, as food or liquids can enter the lungs more easily when lying down.
Choice B reason: Instructing the client to tuck her chin when swallowing can help prevent aspiration pneumonia, as it closes off the airway and directs food or liquids into the esophagus.
Choice C reason: Placing the client in a Fowler's position to eat can help prevent aspiration pneumonia, as it elevates the head and chest and allows gravity to assist with swallowing.
Choice D reason: Encouraging the client to drink water before each meal can increase the risk of aspiration pneumonia, as it can thin out saliva and make it harder to control swallowing.
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