Exhibits
Lamont the procedure, but she also wants to explain some important concepts. What should she include? Select the 4 correct answers, (Case Study #1)
Choose a cuff that is the right size.
Support the extremity.
Have the patient cross their legs while taking blood pressure.
Ensure proper cuff application.
Ensure that the patient is sitting or lying.
Correct Answer : A,B,D,E
A. Choose a cuff that is the right size. Using the correct cuff size is essential for accurate blood pressure readings. A cuff that is too small can falsely elevate readings, while a cuff that is too large can falsely lower them.
B. Support the extremity. The arm should be supported at heart level to prevent unnecessary muscle strain, which could affect blood pressure readings. An unsupported arm may lead to an artificially higher reading.
C. Have the patient cross their legs while taking blood pressure. Crossing the legs can increase blood pressure by reducing venous return and increasing vascular resistance, leading to inaccurate measurements. The patient should keep their feet flat on the floor.
D. Ensure proper cuff application. The cuff should be placed snugly around the upper arm with the artery marker positioned correctly over the brachial artery. Improper placement can lead to inaccurate readings.
E. Ensure that the patient is sitting or lying. Blood pressure should be measured while the patient is in a stable position—either sitting with feet flat on the floor or lying down. Standing may result in postural changes that can alter blood pressure readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.3"]
Explanation
Calculation:
Formula:
Dose to administer (mL) = Ordered dose (mcg) / Available dose (mcg/mL)
Given:
Ordered dose: 400 mcg.
Available dose: 300 mcg/mL.
Volume (mL) = 400 mcg / 300 mcg/mL
= 1.333... mL
Rounded to the nearest tenth: 1.3 mL.
The nurse will administer 1.3 mL of Neupogen.
Correct Answer is D
Explanation
A. Family members report that pain has subsided. Pain is a subjective experience, and the patient's own report is the most reliable indicator of pain relief, not the observations of family members.
B. Vital signs have returned to baseline. While pain can affect vital signs, such as increasing heart rate or blood pressure, their return to normal does not necessarily indicate adequate pain relief. Some patients may still experience significant pain despite stable vital signs.
C. Body language is incongruent with reports of pain relief. Nonverbal cues can be helpful in assessing pain, but they should not override the patient’s self-reported pain level, which is the most accurate measure.
D. You compare assessed pain with baseline pain. The best way to evaluate the effectiveness of PCA analgesia is to assess the patient’s pain level before and after medication administration, comparing it to baseline pain. This provides an objective measure of pain relief.
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