The nurse is assessing vital signs and is preparing to measure the client's blood pressure. Prior to obtaining the blood pressure, what action would be most appropriate?

Inflate the blood pressure cuff 30 mmHg above the point where the radial pulse disappears.

Assist the patient to a standing position for five to ten minutes.

Palpate the radial artery and place your stethoscope lightly over this area.

Measure the blood pressure cuff, ensuring that the cuff encircles 60% of the client’s arm.

Answer and Explanation

The Correct Answer is A

A. Inflating the blood pressure cuff 30 mmHg above the point where the radial pulse disappears is correct. This method, known as the palpatory method, prevents auscultatory gap errors and ensures an accurate blood pressure reading.
B. Assisting the patient to a standing position for five to ten minutes is incorrect unless assessing for orthostatic hypotension. For routine blood pressure measurements, the client should be seated and at rest for at least five minutes.
C. Palpating the radial artery and placing the stethoscope lightly over this area is incorrect because blood pressure is auscultated over the brachial artery, not the radial artery.
D. Measuring the blood pressure cuff to encircle 60% of the client’s arm is incorrect. The correct guideline is that the cuff bladder should encircle at least 80% of the arm circumference, not 60%.

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Correct Answer is C

Explanation

A. Pressing in the right upper quadrant is not appropriate for a referred rebound tenderness test, which is used to assess peritoneal irritation, commonly from appendicitis.
B. Pressing in the left upper quadrant is not useful in diagnosing appendicitis or conditions that cause referred pain to the right lower quadrant.
C. Pressing in the left lower quadrant is correct when performing Rovsing’s sign, a test for referred rebound tenderness. If the client experiences pain in the right lower quadrant when the left lower quadrant is pressed, it suggests peritoneal irritation, often due to appendicitis.
D. Pressing in the right lower quadrant would directly elicit tenderness in appendicitis but does not test for referred rebound tenderness.

A. Client is experiencing a fluid deficit. B. Adventitious sounds are present. C. Hyperinflation of the lungs. D. Client has a pectus carinatum.

Correct Answer is C

Explanation

A. A fluid deficit may cause tachycardia and hypotension, but it does not directly cause diminished lung sounds.
B. Adventitious sounds (wheezes, crackles, rhonchi, etc.) are absent in this case. Diminished breath sounds suggest poor airflow, not abnormal sounds.
C. Hyperinflation of the lungs is correct. In conditions like chronic obstructive pulmonary disease (COPD) or emphysema, lung expansion is limited, leading to diminished breath sounds in all lung fields due to air trapping. The oxygen saturation of 92% is consistent with chronic lung disease.
D. Pectus carinatum (protrusion of the sternum) is a congenital deformity that does not cause diminished breath sounds.

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The nurse is assessing vital signs and is preparing to measure the client's blood pressure. Prior to obtaining the blood pressure, what action would be most appropriate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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