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 use of social media is not included in the COE.”. This statement is not accurate. The use of social media is addressed in the Code of Ethics (COE) for nurses. The COE provides guidance on how nurses should maintain professional boundaries and ethical behavior in the digital age, which includes considerations for social media use.
Choice B rationale:
"Professional expectations are included in the COE.”. This statement is correct. The Code of Ethics (COE) for nurses outlines the professional expectations and standards that nurses are expected to adhere to. It provides guidance on ethical conduct, accountability, and the responsibilities of nurses in their practice.
Choice C rationale:
"Student nurses are not held accountable to COE.”. This statement is not accurate. Student nurses are expected to adhere to the same ethical standards outlined in the Code of Ethics (COE) as registered nurses. While there may be some variations in practice expectations based on the level of training, ethical principles apply to all nurses, including student nurses.
Choice D rationale:
"Criteria for obtaining licensure is included in the COE.”. This statement is not accurate. The Code of Ethics (COE) primarily focuses on ethical principles, professional behavior, and the responsibilities of nurses in their practice. It does not typically include criteria for obtaining licensure, as licensure requirements are determined by licensing boards and regulatory bodies.
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