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 D
Explanation
Choice A rationale:
Standards of care for monitoring clients with a history of blood pressure elevation are important, but they are not the best resource for health promotion activities for clients with hypertension. This choice is more focused on monitoring and care standards.
Choice B rationale:
A critical pathway for clients who have had a stroke is specific to a different condition and not related to health promotion for clients with hypertension. It does not provide the information needed for the presentation.
Choice C rationale:
Acute care facility protocol for clients experiencing a hypertensive crisis is important for managing emergencies, but it is not the best resource for health promotion activities. It deals with crisis management rather than prevention.
Choice D rationale:
Clinical practice guidelines for the management of high blood pressure are the most appropriate resource for the nurse's presentation on health promotion activities for clients with hypertension. These guidelines provide evidence-based recommendations for managing and preventing high blood pressure, making them the best choice for the presentation. .
Correct Answer is B
Explanation
Choice A rationale:
The novice-to-expert model for nursing competence includes several stages, and the "novice" stage represents a beginner who has limited experience and lacks clinical support. This stage typically involves individuals who are just starting their nursing careers and are in the early phases of learning.
Choice B rationale:
An "advanced beginner" is the next stage in the novice-to-expert model. This stage is characterized by individuals who have gained some experience and can perform tasks with increased competence. However, they still require clinical support and guidance in certain situations. It's a transitional phase between complete novice and more proficient levels of competence.
Choice C rationale:
The "proficient" stage in the model represents nurses who have acquired a higher level of competence and are capable of handling a wide range of situations. They do not require the same level of clinical support as those in the advanced beginner stage.
Choice D rationale:
The "competent" stage represents nurses who have reached a high level of competence and can function effectively in most situations without continuous clinical support. They are highly skilled and experienced in their practice.
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