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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Use of accessory muscles

Explanation: Using accessory muscles during breathing indicates increased effort to breathe, which can be a sign of respiratory distress. It suggests that the client is having difficulty breathing and is using additional muscles to aid in the process. This finding should be reported to the practitioner for further evaluation.

B. Nail bed greater than 160 degrees

Explanation: A nail bed angle greater than 160 degrees, also known as clubbing, is an abnormal finding and can be associated with chronic respiratory or cardiovascular conditions. It may indicate insufficient oxygenation and should be reported to the practitioner for evaluation.

C. Circumoral cyanosis

Explanation: Circumoral cyanosis, which is a bluish discoloration around the mouth, indicates inadequate oxygenation. It can be a sign of respiratory or cardiac problems and should be reported to the practitioner for further assessment and intervention.

D. Pursed lip breathing

Explanation: Pursed lip breathing is a technique often used by individuals with respiratory difficulties to improve oxygen exchange. However, if it's observed in a person who does not normally use this technique, it could indicate respiratory distress and should be reported to the practitioner for evaluation.

E. Anteroposterior-to-transverse diameter of 1:1

Explanation: An anteroposterior-to-transverse diameter of 1:1 (also known as barrel chest) is an abnormal finding often associated with chronic obstructive pulmonary disease (COPD). It suggests overinflation of the lungs and can impair effective breathing. This finding should be reported to the practitioner for further evaluation.

Correct Answer is {"dropdown-group-1":"C"}

Explanation

The pacemaker of the heart is known as the sinoatrial (SA) node. The SA node is a specialized group of cells located in the right atrium of the heart. It generates electrical impulses that initiate each heartbeat and set the rhythm for the entire heart.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)

Correct Answer is ["A","B","C","D","E"]

Explanation

A group of nursing students are studying the conduction system of the heart. The nursing students should recognize that the pacemaker of the heart is known as dropdown

Correct Answer is {"dropdown-group-1":"C"}

Explanation

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