The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Which criteria should the nurse use in determining the appropriate-size blood pressure cuff?
The cuff bladder covers 50% to 66% of the length of the upper arm.
The cuff is labeled "toddler.".
The cuff bladder width is approximately 40% of the circumference of the upper arm.
The cuff bladder length covers 80% to 100% of the circumference of the upper arm.
The Correct Answer is A
The correct answer is choice A. The cuff bladder covers 50% to 66% of the length of the upper arm.
Choice A rationale:
Selecting a blood pressure cuff with a bladder that covers 50% to 66% of the length of the upper arm is the appropriate criterion for determining the cuff size for a 2-year-old boy. This range ensures accurate blood pressure measurement by ensuring a proper fit on the arm. If the cuff bladder is too small or too large, it can result in inaccurate readings.
Choice B rationale:
The label "toddler" on the cuff might be helpful in identifying the intended age group, but it doesn't provide precise measurements for cuff sizing. Relying solely on a label might not account for variations in arm sizes within the toddler age group.
Choice C rationale:
The cuff bladder width being 40% of the circumference of the upper arm might not be as accurate as the length-based criterion. A cuff that fits the arm's length is more critical in ensuring proper inflation and accurate blood pressure measurement.
Choice D rationale:
The cuff bladder length covering 80% to 100% of the circumference of the upper arm might result in an excessively large cuff for a 2-year-old, which can lead to inaccurate readings. Length-based sizing is more appropriate for accuracy in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: "I have to stay on strict bed rest for 3 days."
Choice A rationale:
The statement "I should avoid tub baths but may shower" is correct. After a cardiac catheterization, the patient needs to keep the insertion site clean and dry to prevent infection. Showering is allowed, but tub baths should be avoided to minimize the risk of introducing water into the insertion site.
Choice B rationale:
The statement "I have to stay on strict bed rest for 3 days" is incorrect. Bed rest is not typically required after a cardiac catheterization. While the patient might need to lie flat for a few hours after the procedure to prevent bleeding and ensure hemostasis, strict bed rest for three days is unnecessary and could lead to complications like deep vein thrombosis (DVT) or deconditioning.
Choice C rationale:
The statement "I may attend school but should avoid exercise for several days" is correct. Attending school is generally acceptable after a cardiac catheterization, but exercise should be limited for several days to allow the insertion site to heal and to prevent complications like bleeding or hematoma formation.
Choice D rationale:
The statement "I should remove the pressure dressing the day after the procedure" is correct. Pressure dressings are typically removed by healthcare professionals after a specified period, which is usually around 24 hours after the procedure. Removing the dressing on their own the day after the procedure could lead to disruption of the wound and increase the risk of infection.
Correct Answer is D
Explanation
The correct answer is Choice D: Refer children with sore throats for throat cultures.
Choice A rationale:
Recommending salicylates instead of acetaminophen for minor discomforts is not relevant to the prevention of rheumatic fever. Rheumatic fever is primarily associated with untreated streptococcal infections, particularly streptococcal pharyngitis (strep throat), which can lead to complications such as rheumatic fever if left untreated. The choice of pain relievers like salicylates or acetaminophen doesn't play a significant role in preventing rheumatic fever.
Choice B rationale:
Encouraging routine cholesterol screenings is not relevant to the prevention of rheumatic fever. Rheumatic fever is an immune-mediated inflammatory response to certain strains of Streptococcus bacteria, particularly Streptococcus pyogenes. Cholesterol screenings are more related to assessing cardiovascular risk and are not directly linked to preventing rheumatic fever.
Choice C rationale:
Conducting routine blood pressure screenings is not directly related to the prevention of rheumatic fever. Blood pressure screenings are important for identifying hypertension and other cardiovascular risk factors, but they do not have a direct impact on preventing rheumatic fever, which is primarily a complication of untreated streptococcal infections.
Choice D rationale:
Refer children with sore throats for throat cultures. This is the correct choice. Rheumatic fever often develops as a result of untreated streptococcal pharyngitis (strep throat). Throat cultures are crucial for diagnosing streptococcal infections and determining the appropriate course of treatment with antibiotics. By identifying and treating streptococcal infections promptly, the risk of developing rheumatic fever can be significantly reduced.
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