A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg. client sitting up in a chair." Which of the following information should the nurse clarify?
Systolic blood pressure
Location of blood pressure cuff
Unit of measurement
Position of the client
The Correct Answer is B
A. The systolic blood pressure is clearly stated as "102 mm Hg" in the documentation. There is no need for clarification regarding the systolic value.
B. It is essential to document the site where the blood pressure was taken, as this can affect the accuracy of the reading. Typically, the blood pressure is measured in the brachial artery in the upper arm. If the cuff was placed on a different site, such as the wrist or ankle, this should be noted in the documentation.
C. The unit of measurement for blood pressure is correctly indicated as "mm Hg" (millimeters of mercury). There is no need for clarification regarding the unit since it is standard and clear.
D. The position of the client is correctly documented as sitting up in a chair.
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Related Questions
Correct Answer is D
Explanation
A. When a client has a fever, they are at increased risk for dehydration due to fluid loss through sweating and increased metabolic rate. The nurse should encourage adequate fluid intake to help keep the client hydrated.
B. This action is contraindicated. A warming blanket would further elevate the client's body temperature, which is counterproductive when managing a fever. The goal is to help the client cool down, not warm them up.
C. Increasing the room temperature is not advisable. A warmer environment could make the client feel more uncomfortable and may exacerbate their fever. Instead, the nurse should consider cooling measures.
D. Removing excess clothing can help the client cool down and make them more comfortable. It allows for better heat dissipation and can aid in lowering body temperature.
Correct Answer is B
Explanation
A. The systolic blood pressure is clearly stated as "102 mm Hg" in the documentation. There is no need for clarification regarding the systolic value.
B. It is essential to document the site where the blood pressure was taken, as this can affect the accuracy of the reading. Typically, the blood pressure is measured in the brachial artery in the upper arm. If the cuff was placed on a different site, such as the wrist or ankle, this should be noted in the documentation.
C. The unit of measurement for blood pressure is correctly indicated as "mm Hg" (millimeters of mercury). There is no need for clarification regarding the unit since it is standard and clear.
D. The position of the client is correctly documented as sitting up in a chair.
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