The nursing student is practicing blood pressure skills at a screening clinic. After taking a client's blood pressure several times, the student tells the instructor that the Korotkoff's sounds cannot be heard
Prior to the instructor's measuring blood pressure, the nurse should do which of the following to improve accuracy? 1. Have the instructor apologize to the client for repeated cuff inflation.
2. Have the client pump his fist to improve volume of Korotkoff's sounds.
3. Move the cuff to the other arm.
4. Have the client elevate his arm.
3
Rationale: Repeated inflation of the cuff causes false elevation of blood pressure due to repeated engorgement of the artery. The cuff should be moved to the other arm before performing another measurement. The student should have been the one to apologize to the client, and fist pumping will not alter Korotkoff's sounds, although it could have an adverse effect on accuracy of the measurement. Blood pressures should be measured with the brachial pulse at heart level, and elevation of the arm will create a falsely low reading.
You might also like to view...
When planning care for a patient with heart failure, the nurse keeps in mind that this condition may lead to:
A) prerenal AKI. B) intrinsic AKI. C) postrenal AKI. D) glomerulonephritis.
A patient taking highly active antiretroviral therapy (HAART) for a year has the following blood laboratory test values. Which value do you report to the prescriber immediately?
a. White blood cell count 3500 cells/mm3 b. Lactate dehydrogenase 990 IU/L c. Sodium 132 mEq/L d. Hematocrit 32%
The community health nurse manager is reviewing the charts of female elderly clients. Which issue are these clients most likely to experience?
1. Adequate financial resources to purchase medications 2. Senior services that provide transportation to healthcare appointments 3. Multiple medications prescribed by different physicians 4. Medicare that covers healthcare costs so no out-of-pocket expenses occur
A client is complaining of inability to sleep due to a regimen of psychotropic medications. Which of the following interventions would be the least beneficial to the client exhibiting sleep pattern disturbance?
A) Establish a regular bedtime routine. B) Avoid naps during the day. C) Reduce noise. D) Exercise prior to bedtime.