A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

Wrap the blood pressure cuff snugly around the arm.

Place the client's arm above the level of the heart.

Center the cuff bladder over the brachial artery.

Check the instrument gauge to ensure the reading starts at zero.

Answer and Explanation

The Correct Answer is B

A. Wrap the blood pressure cuff snugly around the arm. Wrapping the cuff snugly ensures an accurate blood pressure reading. This statement does not indicate a need for further instruction.

B. Place the client's arm above the level of the heart. The arm should be at the level of the heart, not above. Placing the arm above the heart can result in falsely low blood pressure readings. This action indicates a need for further instruction.

C. Center the cuff bladder over the brachial artery. Proper placement of the cuff bladder over the brachial artery is necessary for an accurate reading. This statement does not indicate a need for further instruction.

D. Check the instrument gauge to ensure the reading starts at zero. Ensuring the gauge starts at zero before taking a reading is necessary to prevent errors. This statement does not indicate a need for further instruction.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Smoking: Smoking is a major modifiable risk factor for atherosclerosis. Cessation can significantly reduce the risk of disease progression.

B. Obesity: Obesity is a modifiable risk factor. Weight loss through diet and exercise can help lower the risk of atherosclerosis.

C. Genetic predisposition: Genetic predisposition is a non-modifiable risk factor. It cannot be changed or controlled, so it is not considered a modifiable factor.

D. Hypertension: Hypertension is a modifiable risk factor, as it can be managed through lifestyle changes and medication.

E. Hypercholesterolemia: Hypercholesterolemia (high cholesterol levels) is a modifiable risk factor because it can be controlled through diet, exercise, and medication.

A. Dyspnea on exertion B. Respiratory depression C. Intense abdominal pain D. Bradycardia

Correct Answer is A

Explanation

A. Dyspnea on exertion: Anemia from blood loss reduces oxygen-carrying capacity, leading to symptoms like fatigue and dyspnea on exertion. The patient's low SpO₂, tachycardia, and increased respiratory rate are consistent with this finding.

B. Respiratory depression: Respiratory depression is typically associated with narcotics or other depressants, not anemia due to blood loss. The increased respiratory rate suggests a compensatory mechanism for decreased oxygenation, not depression.

C. Intense abdominal pain: While abdominal pain could be present in some conditions, it is not a direct symptom of anemia due to surgical blood loss and decreased perfusion.

D. Bradycardia: Anemia usually causes tachycardia (increased heart rate) as the body compensates for the decreased oxygenation, not bradycardia (slow heart rate). Therefore, bradycardia is unlikely in this case.

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A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

Correct Answer is A

Explanation

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