A nurse is teaching a client's spouse about how to obtain a blood pressure reading. Which of the following actions by the spouse indicates a need for further instruction?
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 snugly around the client's arm.
Checks the instrument gauge to ensure the reading starts at zero.
The Correct Answer is B
Choice A rationale:
Placing the cuff bladder over the client's brachial artery is a correct action when obtaining a blood pressure reading. This choice demonstrates proper cuff placement, which is essential for an accurate measurement.
Choice B rationale:
Placing the client's arm above the level of the client's heart is an incorrect action when obtaining a blood pressure reading. The client's arm should be supported at heart level to ensure accurate measurement. This choice indicates a need for further instruction as it could lead to an artificially low blood pressure reading.
Choice C rationale:
Wrapping the blood pressure cuff snugly around the client's arm is a correct action when obtaining a blood pressure reading. This choice demonstrates proper cuff application, which is necessary for accurate results.
Choice D rationale:
Checking the instrument gauge to ensure the reading starts at zero is a correct action when obtaining a blood pressure reading. This choice reflects a proper step to verify that the equipment is calibrated correctly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Love and belonging. Maslow's Hierarchy of Needs outlines a pyramid of human needs, starting from basic physiological needs at the bottom and progressing to higher-level psychological and self-fulfillment needs. Love and belonging are higher-level needs, and individuals typically address them after their basic physiological needs are met. Basic needs like food, water, and shelter take precedence over higher-level emotional needs. In this case, the client's most immediate need would be to satisfy their hunger and thirst.
Choice B rationale:
Psychological security. Psychological security is another higher-level need related to safety and a sense of protection. While it is important, it is not the most immediate need according to Maslow's Hierarchy of Needs. The client would prioritize fulfilling their basic physiological needs before seeking psychological security.
Choice C rationale:
Self-actualization. Self-actualization is the highest level of need in Maslow's Hierarchy, encompassing personal growth, fulfillment, and achieving one's potential. It is a need that individuals pursue once their lower-level needs are satisfied. Since the question pertains to the first need the client would seek to meet, self-actualization is not the correct answer.
Choice D rationale:
Food and water. Food and water are fundamental physiological needs that form the base of Maslow's Hierarchy. These needs must be met before an individual can move on to addressing higher-level needs. Without addressing the need for sustenance, the client's ability to seek love, belonging, security, or self-actualization would be compromised.
Correct Answer is C
Explanation
Choice A rationale:
Justice. Justice refers to fair and equitable treatment for all individuals. While it is an important ethical principle, it does not directly relate to the nurse's action of returning a telephone call promptly and as promised. Justice involves issues of fairness and distribution of resources, and it's not the most applicable principle in this context.
Choice B rationale:
Nonmaleficence. Nonmaleficence refers to the principle of "do no harm." While it is crucial in healthcare, it doesn't directly address the nurse's action of returning a client's call promptly. This principle is more concerned with preventing harm in clinical interventions and decision-making.
Choice C rationale:
Fidelity. Fidelity, or faithfulness, is the ethical principle that aligns with the nurse's action in this scenario. By returning the call by the end of the day as promised, the nurse is demonstrating fidelity to the client's trust and expectations. This principle emphasizes the importance of keeping promises and being loyal to commitments made to clients.
Choice D rationale:
Autonomy. Autonomy pertains to an individual's right to make their own decisions about their care and treatment. While autonomy is a vital principle in healthcare, it does not directly relate to the nurse's action of returning a telephone call promptly. Autonomy focuses more on involving the client in their care decisions and respecting their choices.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
