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 A
Explanation
Choice A rationale:
This situation represents an example of assault. Assault is the threat of bodily harm or unwanted physical contact, which creates an apprehension of fear in the victim. In this case, the laboratory technician's actions of restraining the client's arm against their will for blood drawing without consent is a form of assault as it involves an intentional act causing fear of harm.
Choice B rationale:
While telling a client that the nurse "does not know anything" is unprofessional and disrespectful, it doesn't constitute assault. This scenario is more related to issues of communication and respect rather than a direct threat of physical harm.
Choice C rationale:
Restraining a client at bedtime to prevent wandering is not assault. This scenario might involve ethical considerations and the appropriate use of restraints, but it doesn't meet the legal definition of assault, which involves a threat of physical harm.
Choice D rationale:
Threatening to tie down a client if they try to get up from the chair is an example of assault. This action creates an apprehension of fear in the client by implying a physically harmful act. It's a direct threat that falls under the category of assault.
Correct Answer is B
Explanation
The correct answer is choice B. Necrotic subcutaneous tissue.
Choice A rationale:
Partial-thickness skin loss (Choice A) is characteristic of a stage II pressure ulcer, not a stage III ulcer. A stage II pressure ulcer involves the loss of the epidermis and possibly the dermis, resulting in a shallow open ulcer with a red-pink wound bed.
Choice B rationale:
Necrotic subcutaneous tissue is a manifestation of a stage III pressure ulcer. A stage III ulcer involves full-thickness skin loss where subcutaneous fat may be visible, but exposed bone or muscle is not yet present. Necrotic tissue in the wound bed indicates a more advanced level of tissue damage and the need for appropriate wound care to promote healing.
Choice C rationale:
Blood-filled blisters (Choice C) are not specific to pressure ulcers and are more commonly associated with friction or shear forces. These blisters are not indicative of a stage III pressure ulcer, which involves visible full-thickness tissue loss.
Choice D rationale:
Exposed bone (Choice D) is a characteristic of a stage IV pressure ulcer, not a stage III ulcer. A stage IV ulcer involves extensive tissue loss with exposure of muscle, tendon, or bone. This represents a severe level of tissue damage and requires intensive wound care and management.
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