To accurately take a client's blood pressure, which action by the nurse is most important?

Obtain the blood pressure first thing in the morning.

Use the appropriate size cuff for the client.

Make sure the client is relaxed and comfortable prior to obtaining the blood pressure.

Remove the clothing from arms before obtaining the blood pressure.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Obtaining the blood pressure first thing in the morning is not the most critical factor in accurately measuring blood pressure. Blood pressure can vary throughout the day due to various factors, and it is essential to use the appropriate technique and equipment at any time of the day.

Choice B rationale:

Using the appropriate size cuff for the client is crucial in obtaining an accurate blood pressure reading. If the cuff is too small, it can lead to falsely elevated blood pressure readings, while a cuff that is too large can result in falsely lowered readings. This is because cuff size affects the pressure applied to the artery during measurement.

Choice C rationale:

Ensuring that the client is relaxed and comfortable prior to obtaining the blood pressure is important but not the most critical factor. Anxiety or discomfort can temporarily elevate blood pressure, so it's essential to create a calm and comfortable environment for the client. However, using the correct cuff size is still more critical for accurate measurements.

Choice D rationale:

Removing clothing from the arms before obtaining blood pressure is not the most important action. While it is generally recommended to expose the client's arm for proper cuff placement, it is secondary to using the appropriate cuff size. The cuff should be placed directly on the skin or over a thin layer of clothing, but this step should not take precedence over cuff size selection.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The correct answer is choice a. Retie the restraint straps with a slipknot.

Choice A rationale:

The restraint straps should be tied with a slipknot to ensure that they can be quickly released in case of an emergency. A double knot, as currently used, may delay the removal of the restraints when quick release is necessary.

Choice B rationale:

It is important to check that there is enough space for two fingers to fit beneath the restraints, not three. This ensures that the restraints are secure but not too tight, which could impede circulation.

Choice C rationale:

Restraint straps should not be tied to the side rails because if the side rails are lowered, the restraints could become too tight and cause injury. Instead, they should be secured to a part of the bed frame that moves with the patient.

Choice D rationale:

The padding under the wrist restraints should not be removed as it provides a cushion between the restraints and the patient’s skin, which helps prevent injury and ensures the patient’s comfort.

A. Squeeze the handles together. B. Pull the pin found between the handles. C. Aim the nozzle at the base of the flames. D. Sweep the nozzle back and forth at the base of the flames.

Correct Answer is ["A","C"]

Explanation

Choice A rationale:

Instructing the clients to use the call light is an important action to prevent falls. If the clients need assistance or have to leave their beds, they should use the call light to alert the nurse or healthcare provider. Prompt response to call lights can prevent clients from attempting to move on their own and potentially falling.

Choice B rationale:

Keeping the clients' rooms dark is not a safe practice, especially for clients at risk for falls. Dim lighting can increase the risk of tripping or falling, especially during nighttime when visibility is already reduced. Adequate lighting in the clients' rooms is essential to ensure their safety.

Choice C rationale:

Moving overbed tables away from the bed is crucial in preventing falls. Overbed tables can obstruct the clients' movement, leading to accidents. By keeping the area around the bed clear, the clients have more space to maneuver safely, reducing the risk of falls.

Choice D rationale:

Performing client checks every 4 hours is a good practice, but it is not sufficient for clients at high risk for falls, especially during the night shift when they may need assistance to use the bathroom or move in bed. Frequent checks and availability to assist clients promptly are essential to prevent falls effectively.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

To accurately take a client's blood pressure, which action by the nurse is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

The nurse is extinguishing a fire that has broken out in the workplace.Which is the first step the nurse should take?

Correct Answer is ["A","C"]

Explanation

To accurately take a client's blood pressure, which action by the nurse is most important?

How often must you or an assistant check on a patient who is restrained?

The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?

A nurse explains to a client that it is important to slowly change positions to diminish or eliminate the symptoms of what?

Which vowel is most commonly used when combining word parts?

A nurse is preparing to open a sterile pack. The nurse has performed the task correctly when the nurse demonstrates what?

Which suffix means narrowing?

A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the following statements should the nurse identify as an indication that the client understands the instructions?