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 B

Explanation

Choice A rationale:

Stage I Pressure ulcer - This choice is not correct because a Stage I pressure ulcer is characterized by intact skin with non-blanchable redness over a bony prominence. There is no partial-thickness skin loss at this stage.

Choice B rationale:

Stage II Pressure ulcer - This is the correct choice. A Stage II pressure ulcer involves partial-thickness skin loss that presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also manifest as an intact or open/ruptured serum-filled blister.

Choice C rationale:

Stage IV Pressure ulcer - This choice is not correct because a Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. There is no mention of such extensive tissue loss in the given scenario.

Choice D rationale:

Stage II Pressure ulcer - This choice is a duplicate of Choice B and is not correct for the reasons stated above.

A. Dyspnea. B. Clubbing of the fingers. C. Deep respirations. D. Bradycardia. E. Barrel chest.

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

Explanation

Choice A rationale:

Dyspnea (shortness of breath) is a common finding in clients with emphysema. Emphysema is a chronic obstructive pulmonary disease characterized by the destruction of lung tissue, leading to reduced lung elasticity and airflow limitation, which can result in difficulty breathing.

Choice B rationale:

Clubbing of the fingers is another expected finding in clients with advanced emphysema. Clubbing is the swelling and rounding of the fingertips, often associated with chronic respiratory conditions. It is thought to be a result of chronic hypoxia and inadequate oxygenation.

Choice C rationale:

Deep respirations are not typically associated with emphysema. Clients with emphysema often exhibit shallow, rapid respirations due to the loss of lung tissue elasticity, which impairs the normal respiratory mechanics.

Choice D rationale:

Bradycardia (slow heart rate) is not a common finding in emphysema. Emphysema primarily affects the respiratory system and does not directly influence heart rate. Bradycardia could be related to other factors but is not a characteristic finding of emphysema.

Choice E rationale:

Barrel chest is a classic physical finding in clients with emphysema. It results from the hyperinflation of the lungs due to the trapping of air in the damaged alveoli. This gives the chest a rounded appearance, similar to the shape of a barrel.

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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

A nurse is admitting an elderly client into a unit. During the initial assessment, the nurse notes an erythematous wound with partial-thickness skin loss. The wound does not contain slough and is located on the patient's right heel. How will the nurse stage this pressure ulcer?

Correct Answer is B

Explanation

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to see in this client? (Select all that apply.).

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

Explanation

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