A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?
Checks the instrument gauge to ensure the reading starts at zero
Centers the cuff bladder over the client's brachial artery
Places the client's arm above the level of the client's heart
Wraps the blood pressure cuff around the client's arm using firm pressure
The Correct Answer is C
A. Checks the instrument gauge to ensure the reading starts at zero:
This action is correct. Before taking a blood pressure reading, it's essential to ensure that the instrument's gauge starts at zero. This ensures accurate measurement as the reading reflects the pressure above zero.
B. Centers the cuff bladder over the client's brachial artery:
This action is correct. Proper placement of the blood pressure cuff over the brachial artery is crucial for accurate readings. Centering the cuff ensures that the artery is correctly compressed for measurement.
C. Places the client's arm above the level of the client's heart:
This action is incorrect. Placing the arm above heart level can result in a falsely low blood pressure reading. The arm should be at the same level as the heart to obtain an accurate measurement.
D. Wraps the blood pressure cuff around the client's arm using firm pressure:
This action is correct, but it's important to note that while the cuff should be snug, it should not be too tight or too loose. Wrapping the cuff with firm, even pressure ensures proper compression of the artery for an accurate measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The pupils constrict when the examiner's index finger slowly moves toward the client's nose.
This statement is correct. Visual accommodation is the process by which the eye's lens changes shape to focus on objects at varying distances. When an object moves closer to the eyes, the pupils constrict to adjust and focus on the near object, preventing double vision.
B. The client involuntarily blinks in the presence of bright light directed over the pupils during the eye exam.
This statement describes the pupillary light reflex, not visual accommodation. The pupillary light reflex is the response of the pupils to light exposure.
C. The client's peripheral vision becomes sharper when the examiner shines a light over the pupils.
This statement is not accurate. Peripheral vision sharpness is not related to visual accommodation. Visual accommodation mainly involves adjusting focus for objects at varying distances.
D. The pupils dilate when the examiner's index finger slowly moves toward the client's nose.
This statement is incorrect. Pupils should constrict, not dilate, when focusing on a near object (as in visual accommodation). Dilation occurs in low-light conditions or in response to sympathetic stimulation.
Correct Answer is D
Explanation
A. Listening for all possible sounds at a time at each specified area: This approach does not allow for specific localization of different heart sounds and murmurs, making it difficult to accurately assess the heart's condition.
B. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This option is close but lacks the systematic approach of method D. Listening at specific anatomical locations (aortic, tricuspid, pulmonic, mitral) is important, but the Z pattern allows for thorough coverage and precise localization of any abnormal sounds.
C. Listening to the sounds only at the site where the apical pulse is felt to be the strongest: This method does not cover all the important auscultation sites on the heart and may miss significant findings.
D. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex: This technique involves a systematic approach where the nurse listens at specific locations in a structured manner, ensuring comprehensive coverage of the heart sounds and murmurs.
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