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 C
Explanation
The correct answer is C. Tuberculosis.
Choice A rationale:
Scabies is a skin infestation caused by mites, and it does not require airborne precautions. Standard precautions, such as gloves and hand hygiene, are sufficient.
Choice B rationale:
Mycoplasmal pneumonia is typically spread through droplets, and a regular surgical mask is usually adequate for protection.
Choice C rationale:
Tuberculosis (TB) is an airborne disease, and healthcare workers need to wear an N95 respirator to protect themselves from inhaling the bacteria.
Choice D rationale:
Scarlet fever is spread through respiratory droplets, but it does not require airborne precautions. Standard precautions are usually enough.
Correct Answer is C
Explanation
Choice A rationale:
This option is incorrect. Counting a regular pulse for 30 seconds and doubling the number is an appropriate method for assessing heart rate, not peripheral pulses. When assessing peripheral pulses, it is important to count the pulses directly for a full minute to accurately determine the pulse rate. This ensures that any irregularities or variations in the pulse rate are captured.
Choice B rationale:
This option is incorrect. Palpating the femoral artery in the groin is a standard method for assessing peripheral pulses. It is not a safety issue when performed correctly. However, the question asks about a safety issue related to assessing peripheral pulses.
Choice C rationale:
Palpating both carotid pulses at the same time is a safety issue when assessing peripheral pulses. Simultaneously palpating both carotid pulses can lead to excessive pressure on the carotid sinuses, which are baroreceptors located in the carotid arteries. Stimulation of these baroreceptors can result in a reflex decrease in heart rate and blood pressure, leading to a condition known as carotid sinus hypersensitivity. This can cause dizziness, fainting, or, in extreme cases, cardiac arrest. Therefore, it is essential to avoid palpating both carotid pulses simultaneously to prevent adverse reactions in clients, especially those with cardiovascular issues.
Choice D rationale:
Palpating the radial artery on the thumb side of the wrist is a standard method for assessing peripheral pulses. It is a safe and commonly used technique for evaluating radial pulse rate, rhythm, and amplitude. .
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