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:
Justice is the ethical principle related to fairness and equality in healthcare. It is not applicable in this scenario as it does not address the nurse's action of returning at 1400 for wound care.
Choice B rationale:
Autonomy is the principle that respects a patient's right to make decisions about their own healthcare. While important, this is not the focus of the nurse's action in this scenario.
Choice C rationale:
Veracity refers to truthfulness and honesty in healthcare. The nurse returning at the agreed time of 1400 does not primarily relate to veracity. It is more about keeping a commitment.
Choice D rationale:
Fidelity, or faithfulness, is the ethical principle that the nurse is demonstrating in this scenario. The nurse is keeping their commitment to provide wound care at the agreed time of 1400. This aligns with the principle of fidelity.
Correct Answer is A
Explanation
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