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 B
Explanation
A. This activity is related to primary prevention, focusing on health promotion and preventing illness. It aims to educate clients on lifestyle choices that can prevent health problems.
B. Tertiary care involves specialized treatments and interventions for severe or complex health issues. Assisting with transplant surgery is a highly specialized procedure that falls under tertiary care, as it addresses advanced medical conditions requiring significant intervention.
C. Similar to option A, this activity focuses on health promotion and prevention. Teaching about exercise programs is part of primary care, aiming to improve overall health and prevent future health issues.
D. This activity is part of secondary care. Recommending regular exams is aimed at early detection of potential health issues, allowing for timely intervention. It does not reflect the specialized care provided in tertiary healthcare.
Correct Answer is ["A","B","F"]
Explanation
A. This is indeed a fundamental aspect of nursing as per the ANA's definition. Nurses work to protect and promote health for their clients.
B. This statement accurately reflects the ANA's emphasis on the nursing process as a systematic approach to delivering care.
C. This does not align directly with the ANA's definition, which focuses more on the roles and responsibilities of nurses rather than assisting others in decision-making.
D. While knowledge of laws and regulations is essential for nurses, the ANA's definition does not state that nursing involves providing these laws.
E. While this is important in nursing, the ANA's definition specifically emphasizes protecting and promoting health rather than solely focusing on avoidance.
F. Advocacy is a key component of nursing practice and is explicitly recognized in the ANA's definition.
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