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.
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)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
When preparing to open a sterile pack, the nurse must touch only the inner surface of the inner wrapper to maintain sterility. This is a fundamental principle of aseptic technique. Sterile items should be handled with care to prevent contamination. By touching only the inner surface of the inner wrapper, the nurse ensures that the contents of the pack remain sterile and safe for use in medical procedures. Any contact with the outer surface or other non-sterile items can compromise the sterility of the contents.
Choice A rationale:
Placing the sterile pack on a clean surface is a good practice but does not ensure the maintenance of sterility. Sterile items should be placed on a sterile surface or field to prevent contamination. Placing the pack on a clean surface may still expose it to potential contaminants, compromising its sterility.
Choice B rationale:
Turning the pack so that the first flap faces the nurse's body is incorrect. The first flap should be opened away from the nurse to avoid the risk of contamination. By opening the flap away from the nurse, any potential contaminants in the air are less likely to come into contact with the sterile contents.
Choice C rationale:
Opening the right-side flap first is not a standard practice for opening a sterile pack. The choice of which side to open first may vary based on individual preference or the design of the packaging. The key factor is to maintain the sterility of the contents by handling the pack appropriately, as mentioned in choice D.
Correct Answer is D
Explanation
Choice B rationale:
Call for additional staff to assist with the transfer. The nurse's priority in this situation is ensuring the safety of the client during the transfer from the chair to the bed. Calling for additional staff provides the necessary support to safely move the client, minimizing the risk of falls or injuries. It is crucial to have an adequate number of staff members to assist in transfers, especially when the client's mobility is compromised.
Choice A rationale:
Obtain a walker for the client to use to transfer back to bed. While a walker can be helpful for mobility, the client has already asked to return to bed, indicating the immediate need for assistance. Waiting to obtain a walker could delay the transfer, potentially putting the client at risk.
Choice C rationale:
Use a transfer belt and assist the client back into bed. Using a transfer belt is a suitable technique for assisting clients with mobility. However, the nurse's priority in this scenario is to ensure there is enough staff assistance to guarantee a safe transfer. The nurse should not attempt to perform the transfer alone, even with a transfer belt, as it might be unsafe for both the nurse and the client.
Choice D rationale:
Determine the client's ability to help with the transfer. While assessing the client's ability to participate in the transfer is important, it is not the nurse's priority in this situation. The immediate concern is to secure adequate assistance to safely move the client back to bed.
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