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.
Position of the client.
Unit of measurement.
Location of blood pressure cuff.
The Correct Answer is D
The correct answer is choice d. Location of blood pressure cuff.
Choice A rationale: The systolic blood pressure of 102 mm Hg is within a normal range and does not require clarification.
Choice B rationale: The position of the client, “sitting up in a chair,” is clearly documented and does not need further clarification.
Choice C rationale: The unit of measurement, “mm Hg,” is the standard unit for blood pressure and is correctly documented.
Choice D rationale: The location of the blood pressure cuff is not specified in the documentation. It is important to document whether the blood pressure was taken on the left or right arm, or another location, to ensure accuracy and consistency in future measurements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct Answer is D
Explanation
The correct answer is Choice D: Obtaining a blood pressure for a client who is to be discharged later in the day.
Choice A rationale:
Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).
Choice B rationale:
Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.
Choice C rationale:
Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.
Choice D rationale:
Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.
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