The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?
Explain the procedure to the child.
Choose the cuff that says "Child" instead of "Infant."
Use the diaphragm portion of the stethoscope to detect Korotkoff sounds.
Obtain the reading before the child has a chance to settle down
The Correct Answer is A
A. Explain the procedure to the child. Explaining procedures in an age-appropriate manner helps reduce anxiety and increases cooperation. A 3-year-old can understand simple instructions, so explaining what will happen can help them remain calm.
B. Choose the cuff that says "Child" instead of "Infant." Blood pressure cuffs should be appropriately sized for accurate readings. A cuff that is too small can result in falsely high readings, while a cuff that is too large can produce falsely low readings.
C. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. The bell of the stethoscope is best for detecting low-pitched sounds, including Korotkoff sounds.
D. Obtain the reading before the child has a chance to settle down. A child who is upset, crying, or anxious may have an elevated blood pressure reading due to stress. It is best to allow the child to calm down before obtaining an accurate measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Making a clinical decision in the patient's best interest: Making decisions in the patient’s best interest is an essential part of nursing practice and demonstrates good clinical judgment.
B. Making a clinical decision based on previous shift assessments. Nursing assessments should be conducted for each shift, as a patient’s condition can change rapidly. Relying on previous assessments without reassessing can lead to missed changes in the patient’s status, potentially causing harm.
C. Making an ethical clinical decision. Ethical decision-making is an integral part of nursing practice and aligns with professional standards. There is no need for intervention if the decision is ethical.
D. Making an informed clinical decision. Informed clinical decision-making is based on current patient data, clinical guidelines, and critical thinking. This is a correct approach to nursing care and does not require intervention.
Correct Answer is C
Explanation
A. Utilizing evidence-based practice based on nurses' needs: Professional standards focus on patient-centered care, not the nurse's needs. Evidence-based practice should prioritize patient safety and effectiveness.
B. Establishes minimal passing standards for testing: While professional standards guide nursing education and testing, their primary role is to guide clinical decision-making for patient care.
C. Uses critical thinking for the highest level of quality nursing care: Professional standards provide guidelines for best practices, ensuring nurses apply critical thinking and clinical judgment to improve patient outcomes.
D. Bypasses the patient's feelings to promote ethical standards: Ethical nursing practice includes patient advocacy, not bypassing patient emotions or concerns.
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