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 B
Explanation
A. 108/60 mm Hg: This is considered normal blood pressure and does not indicate hypertension.
B. 134/86 mm Hg: According to the current guidelines, stage 1 hypertension is defined as systolic 130-139 mm Hg or diastolic 80-89 mm Hg. This client's blood pressure falls into that category.
C. 164/104 mm Hg: This is classified as stage 2 hypertension, which is defined by systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg.
D. 128/68 mm Hg: This is considered elevated blood pressure, not stage 1 hypertension. Stage 1 begins at systolic BP of 130 mm Hg.
Correct Answer is D
Explanation
A. Check for orthostatic hypotension. While important, checking for orthostatic hypotension is not the priority action in a hypertensive emergency, where rapid blood pressure reduction is necessary.
B. Assist the client to make lifestyle changes. Assisting the client with lifestyle changes is part of long-term blood pressure management but is not a priority action when administering nicardipine for acute hypertension.
C. Instruct the client to restrict sodium intake. Sodium restriction is a key component of managing hypertension but is not the priority action during an acute hypertensive crisis.
D. Monitor the client's BP every 5 minutes. In a hypertensive crisis, frequent monitoring of the client’s blood pressure is essential to ensure the medication is lowering blood pressure safely and effectively.
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