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
Choice A rationale:
In this scenario, the nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). By collecting evidence-based information and research on this topic, the nurse is acting in the role of a researcher. Research in healthcare is essential to stay current with best practices, guidelines, and recommendations, and it helps inform clinical decision-making.
Choice B rationale:
A nurse manager is responsible for overseeing nursing staff, unit operations, and ensuring that the unit operates efficiently and safely. While a nurse manager may use evidence-based information to guide decisions, the primary role described in this scenario is that of a researcher, as the nurse is focused on gathering evidence-based practice on a specific topic.
Choice C rationale:
An educator's primary role is to teach and educate others, such as patients, families, or fellow healthcare professionals. While education often involves the use of evidence-based information, in this scenario, the nurse is primarily focused on gathering evidence rather than directly educating others.
Choice D rationale:
A case manager is responsible for coordinating and managing a patient's care, often involving multiple aspects of healthcare and social services. While case managers may use evidence-based information in their decision-making, the primary role described in this scenario is that of a researcher, as the nurse is focused on gathering evidence-based practice related to CAUTI, not managing a specific patient's case.
Correct Answer is A
Explanation
Choice B rationale:
The statement "The ACA is primarily for individuals requiring tertiary care" is not accurate. The Affordable Care Act (ACA) is designed to improve access to healthcare for a broad range of individuals, not just those in need of tertiary care. It aims to make healthcare coverage more affordable and accessible for all, regardless of the level of care needed.
Choice C rationale:
The statement "Individuals must qualify to participate in ACA insurance coverage" is correct to some extent. Individuals must meet certain eligibility criteria to enroll in ACA insurance plans, such as being a U.S. citizen or lawfully present, but it does not capture the full scope of the ACA's purpose. The primary goal of the ACA is to expand access to healthcare and reduce disparities, not just limited to qualification requirements.
Choice D rationale:
The statement "Individuals with pre-existing conditions are not eligible for ACA coverage" is incorrect. One of the significant achievements of the ACA is that it prohibits insurance companies from denying coverage to individuals with pre-existing conditions. In fact, the ACA has provisions to protect individuals with pre-existing conditions and ensure their access to insurance coverage.
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