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 C
Explanation
Choice A rationale:
The role of a case manager involves coordinating and managing a client's care across various healthcare providers and services. This role focuses on the coordination of care and resources, not obtaining informed consent.
Choice B rationale:
The nurse manager is responsible for managing and overseeing nursing staff within a healthcare unit or department. Their primary role is related to administration and staff supervision, not obtaining informed consent.
Choice D rationale:
Researchers are individuals who conduct research studies and investigations to generate new knowledge and evidence. Their role is not related to obtaining informed consent from clients.
Choice C rationale:
The nurse is demonstrating the role of an advocate when obtaining informed consent from a client. Advocacy involves supporting the client's right to make informed decisions about their care. The nurse ensures that the client has all the necessary information, understands the procedure or treatment, and consents voluntarily. This includes explaining the risks and benefits, answering questions, and advocating for the client's autonomy and self-determination.
Correct Answer is B
Explanation
Answer and explanation
The correct answer is choice B.
Choice A rationale:
Yoga involves gentle stretching and may not directly impact the phlebitis.
Choice B rationale:
Therapeutic massage could potentially dislodge a clot in the leg, leading to a dangerous condition called a pulmonary embolism.
Choice C rationale:
Acupressure, like yoga, involves gentle pressure and may not directly impact the phlebitis.
Choice D rationale:
Acupuncture involves the insertion of needles and could potentially cause harm, but it is less likely to dislodge a clot than massage.
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