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 C

Choice A rationale:

This option is incorrect. Tachypnea refers to abnormally fast breathing, typically defined as a respiratory rate higher than 20 breaths per minute in adults. It is the opposite of the condition described in the question, where the respiratory rate has fallen below 10 respirations per minute.

Choice B rationale:

This option is incorrect. Apnea refers to the absence of breathing, often resulting from a temporary cessation of airflow to the lungs. It is characterized by the complete absence of respiratory movements and sounds, which is different from the situation described in the question where the client is breathing at a very slow rate.

Choice C rationale:

Bradypnea, or abnormally slow breathing, is the correct answer in this case. It is defined as a respiratory rate lower than the normal range, which is typically between 12 to 20 breaths per minute in adults. Bradypnea can be caused by various factors, including drug overdose, neurological disorders, or metabolic imbalances. In this scenario, the client's slow respiratory rate (below 10 respirations per minute) indicates bradypnea.

Choice D rationale:

This option is incorrect. Eupnea refers to normal breathing, where the rate and depth of respirations are within the normal range. It does not describe the condition of the sedated client in the question, who is experiencing abnormally slow breathing (bradypnea)

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Correct Answer is D

Explanation

Choice A rationale:

Ears are located on the sides of the head, not between the cranial and thoracic cavities. The ears are lateral structures on the head.

Choice B rationale:

Elbow is a joint located in the upper limb, specifically in the arm. It is not between the cranial and thoracic cavities. The elbow is a joint that allows the forearm to bend.

Choice C rationale:

Knee is a joint in the lower limb, connecting the thigh bone to the shin bone. It is not located between the cranial and thoracic cavities. The knee joint allows for movements like bending and straightening of the leg.

Choice D rationale:

The nape of the neck refers to the back of the neck. It is the posterior part of the neck, located between the cranial (head) and thoracic (upper chest) cavities. The nape of the neck is a specific anatomical location.

A. Counting a regular pulse for 30 seconds and doubling the number to obtain the rate. B. Palpates the femoral artery in the groin of the client. C. Palpates both carotid pulses at the same time. D. Palpates the radial artery on the thumb side of the wrist.

Correct Answer is A

Explanation

Choice A rationale:

The client's respirations are faster and deeper than normal due to expelling too much carbon dioxide. This condition is known as hyperventilation. Hyperventilation can occur due to various reasons such as anxiety, pain, fever, or metabolic acidosis. When the body expels excessive carbon dioxide, it leads to respiratory alkalosis, resulting in faster and deeper breathing to compensate for the decrease in carbon dioxide levels in the blood.

Choice B rationale:

This option is incorrect. Hypoxemia, or low blood oxygen levels, typically leads to rapid, shallow breathing (tachypnea) rather than deep and fast respirations.

Choice C rationale:

This option is incorrect. Inflammation of the phrenic nerve does not directly affect the depth and rate of respirations. Phrenic nerve inflammation is more likely to cause pain during breathing or hiccups.

Choice D rationale:

This option is incorrect. Using intercostal muscles to breathe is a normal physiological process, especially during deep or labored breathing. However, it does not explain the specific situation described in the question, where the respirations are faster and deeper than normal.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which body part is in the following location? Posterior and between the cranial and thoracic cavities.

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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