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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. This entry reflects the client’s personal experience and perception of the rash. It is not measurable and relies on the client’s description.
B. This statement is also based on the client’s experience and feelings about their condition after taking medication. It is a personal report and not an observable finding.
C. This is an observation made by the nurse. The description of the rash is measurable and can be documented as a physical finding.
D. Similar to options A and B, this entry describes the client’s perception of pain. It is a personal
experience that cannot be directly measured.
E. This is a measurable finding obtained through a thermometer. It provides concrete evidence of the
client’s condition and does not rely on the client’s report.
Correct Answer is ["A","B","C","D"]
Explanation
A. If any interventions were taken in response to abnormal blood pressure readings (e.g., administering medication, adjusting treatment plans), it should be recorded to provide a complete picture of the
client’s care.
B. This is also crucial information to include. Blood pressure readings can vary based on the client's position (e.g., sitting, standing, lying down), so documenting the position helps provide context for the reading and ensures consistency in monitoring.
C. This is important to document as well. Indicating whether the blood pressure was taken on the right arm, left arm, or another site (like the thigh) is necessary, as different sites can yield different readings and can be relevant for assessing trends over time.
D. Documenting the client’s response to any interventions is vital. This includes how the client reacted to medications or changes in treatment based on their blood pressure readings. It helps in evaluating the effectiveness of interventions and planning future care.
E. This information is not typically documented in the context of a specific blood pressure reading. While it’s important for care planning to know how often blood pressure should be monitored, the actual frequency does not need to be recorded with each individual reading.
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