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 B

Explanation

A. "I can eat frozen juice bars for a snack." Frozen juice bars are generally low in sodium and are a healthy snack option for clients with hypertension. This choice is acceptable as long as they are made from 100% juice and do not contain added sugars or sodium.

B. "I can have a cola drink twice a day." Cola drinks contain caffeine, sugar, and sometimes sodium, which can increase blood pressure. Clients with hypertension should limit their intake of sugary or caffeinated drinks. This statement indicates a need for further teaching.

C. "I will replace table salt with dried herbs." Replacing table salt with dried herbs is a good practice to reduce sodium intake, which can help manage hypertension. This statement does not indicate a need for further teaching.

D. "Fresh fruits are good to include with meals." Fresh fruits are low in sodium and rich in potassium, which can help regulate blood pressure. This is a good dietary choice for clients with hypertension and does not indicate a need for further teaching.

A. Valve disorder B. Asthma C. Pulmonary embolism D. Heart failure

Correct Answer is D

Explanation

A. Valve disorder: While valve disorders can cause fatigue and dyspnea, the client’s history of hypertension, tachycardia, hypercholesteremia, and medication noncompliance are more suggestive of heart failure rather than a valve disorder.

B. Asthma: Asthma typically presents with wheezing, shortness of breath, and chest tightness. It is less likely to be the cause of symptoms in this scenario, where cardiac conditions and medication noncompliance are noted.

C. Pulmonary embolism: While pulmonary embolism can cause dyspnea and tachycardia, the client's chronic cardiovascular history and edema are more consistent with heart failure than an acute pulmonary embolism.

D. Heart failure: The client has a history of hypertension, tachycardia, and hypercholesteremia, along with medication noncompliance, tachycardia, and edema. These are classic signs of heart failure, making this the most likely diagnosis

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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

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Explanation

Correct Answer is D

Explanation

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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?