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 A
Explanation
Choice A reason: Offering the client frozen banana as a snack is an appropriate intervention for the nurse to take because it can help soothe and cool the inflamed mucous membranes in the mouth and throat, which are caused by stomatitis. Stomatitis is an inflammation of the oral cavity that can result from radiation therapy or chemotherapy. Frozen banana also provides potassium, vitamin C, and fiber for the client.
Choice B reason: Serving the client hot meals is not an appropriate intervention for the nurse to take because it can worsen nausea and vomiting. Hot meals are aromatic, spicy, and greasy, which are characteristics of emetic foods. Hot meals can also irritate the stomach lining and trigger the gag reflex.
Choice C reason: Avoiding serving sauces or gravies is not an appropriate intervention for the nurse to take because it can cause dehydration and malnutrition. Sauces and gravies are liquid, mild, and moist, which are characteristics of antiemetic foods. Sauces and gravies can also enhance the flavor and texture of bland foods and provide calories and nutrients for the client.
Choice D reason: Discouraging the use of a straw is not an appropriate intervention for the nurse to take because it can prevent adequate fluid intake and hydration. Using a straw can help the client sip small amounts of clear liquids, such as water, ginger ale, or broth, which are antiemetic fluids. Using a straw can also reduce the exposure to odors and tastes that may cause nausea.
Correct Answer is C
Explanation
Choice A reason: Eating more tuna is not an appropriate food choice for a client who has gout because it is high in purines, which are substances that break down into uric acid in the body. Uric acid can form crystals in the joints and cause inflammation and pain, which are symptoms of gout. Tuna should be limited or avoided by clients who have gout.
Choice B reason: Eating more red meat is not an appropriate food choice for a client who has gout because it is high in purines, which are substances that break down into uric acid in the body. Uric acid can form crystals in the joints and cause inflammation and pain, which are symptoms of gout. Red meat should be limited or avoided by clients who have gout.
Choice C reason: Eating blueberries every morning is an appropriate food choice for a client who has gout because they are low in purines and high in antioxidants, which are substances that protect the cells from damage caused by free radicals. Antioxidants can help reduce inflammation and pain, which are symptoms of gout. Blueberries also provide vitamin C, fiber, and water for the client.
Choice D reason: Eating bananas for a snack is not an appropriate food choice for a client who has gout because they are high in fructose, which is a type of sugar that can increase uric acid levels in the blood. Fructose can worsen gout attacks by triggering inflammation and pain in the joints. Bananas should be limited or avoided by clients who have gout.
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