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.
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Correct Answer is D
Explanation
Choice A rationale:
Explaining to the client that he needs the protein in the milk and the beef is not an appropriate action. Understanding and respecting the client's religious and dietary preferences are essential. Orthodox Jewish dietary laws, known as kashrut, prohibit the consumption of certain foods, including the mixing of meat and dairy in the same meal. This response disregards the client's faith-based dietary restrictions.
Choice B rationale:
Allowing the AP to deliver the food tray to the client is not appropriate in this situation. The nurse is responsible for ensuring that the client's dietary needs and preferences are met, especially when there are religious considerations involved. Failing to accommodate the client's dietary requirements could lead to non-compliance and potential harm.
Choice C rationale:
Replacing the nonfat milk with apple juice does not address the client's religious dietary restrictions. While the change may avoid mixing meat and dairy, it still disregards the importance of providing a kosher meal. Kosher dietary laws encompass more than just avoiding meat and dairy combinations. It is important to provide a fully compliant kosher meal.
Choice D rationale:
Calling the dietary department and asking for a kosher tray is the appropriate action. A kosher diet adheres to specific rules and regulations, including the separation of meat and dairy products. To respect the client's faith and dietary needs, the nurse should ensure that the food provided aligns with kosher guidelines. This choice demonstrates cultural sensitivity and ensures the client's well-being.
Correct Answer is C
Explanation
Choice A rationale:
Cranberry juice causing bad breath is not a well-known side effect or outcome associated with its consumption. This information is not a commonly taught aspect of cranberry juice use.
Choice B rationale:
Bloating is not a common or widely recognized outcome of drinking cranberry juice. While cranberry juice might have some gastrointestinal effects, bloating is not a significant concern associated with its consumption.
Choice C rationale:
Informing the client that drinking cranberry juice daily can prevent recurrent urinary tract infections is accurate. Cranberry juice is often recommended for its potential to reduce the risk of urinary tract infections due to its anti-adhesive properties that may inhibit the adherence of bacteria to the urinary tract.
Choice D rationale:
Cranberry juice's effect on lowering cholesterol is not a well-established benefit of its consumption. Cholesterol management typically involves dietary changes, exercise, and sometimes medications, but cranberry juice is not a primary intervention for this purpose.
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