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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is "{\"xRanges\":[80.828125,100.828125],\"yRanges\":[129,149]}"
Explanation
To auscultate the apical pulse, the nurse should place the stethoscope at the fifth intercostal space at the midclavicular line on the left side of the chest. This is the location of the apex of the heart, also referred to as the point of maximal impulse (PMI).
Correct Answer is C
Explanation
A. Schedule an appointment for a prostate-specific antigen (PSA) test. PSA screening is typically considered for men aged 50 and older, or earlier for those with higher risk factors like family history. Since the client does not mention any risk factors, this option is not a priority.
B. Schedule his next appointment for 1 year from now. While it is standard for clients without significant health issues to have annual exams, the nurse should prioritize education on risk factors related to hypertension, given the client's slightly elevated blood pressure.
C. Provide information about how to reduce risk factors of hypertension. Even though the client's blood pressure is in the elevated category, it is important to educate him about how to reduce the risk of developing hypertension, particularly since he is African-American, which is a population at higher risk for hypertension.
D. Provide information for a weight loss plan that includes increasing physical activity. The client has a normal BMI of 24, so weight loss would not be necessary. However, regular physical activity is important for overall cardiovascular health.
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