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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Veracity refers to truthfulness and honesty in communication between the healthcare provider and the client. It involves providing accurate information and not deceiving the client. Discontinuing the experimental medication due to kidney failure demonstrates a commitment to the truth, but the primary ethical principle demonstrated here is nonmaleficence.

Choice B rationale:

Autonomy refers to respecting the client's right to make their own decisions about their healthcare. In this scenario, the medication was discontinued due to evidence of harm to the client's health. This action prioritizes the client's well-being over their autonomy to continue the treatment.

Choice C rationale:

Nonmaleficence, or the principle of "do no harm," is demonstrated in this scenario. The experimental medication was discontinued because it was causing rapidly advancing kidney failure. The healthcare provider's decision to stop the treatment is an example of prioritizing the client's safety and well-being by preventing further harm.

Choice D rationale:

Fidelity refers to being loyal, keeping promises, and maintaining trust in the nurse-client relationship. While this principle is important, it doesn't directly apply to the situation described, where the focus is on the ethical responsibility to prevent harm.

A. The left fifth intercostal space at the midclavicular line. B. The left fifth intercostal space. C. The left second intercostal space. D. The right second intercostal space.

Correct Answer is C

Explanation

A. The left fifth intercostal space at the midclavicular line is the location for palpating the apical pulse, not the pulmonic area. This area is used to assess the heart's apex, particularly for detecting the point of maximal impulse (PMI).

B. The left fifth intercostal space is also associated with the apical pulse, but it lacks the specificity of the midclavicular line, making it less precise for identifying the pulmonic area.

C. The left second intercostal space is the correct location for palpating the pulmonic area. This area is where the pulmonic valve is best auscultated and palpated, allowing for the detection of any abnormal pulsations or sounds related to the pulmonary artery.

D. The right second intercostal space is the location for palpating the aortic area, not the pulmonic area. This site is used to assess the aortic valve and any related abnormalities.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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