The nurse is assessing a patient's blood pressure. Which of the following would increase the risk of inaccurate measurement?
1. using a noninvasive blood pressure machine
2. measuring the blood pressure in both arms
3. using a cuff where the bladder encircles the arm by 60 percent
4. measuring the blood pressure 10 minutes after exercising
3
Rationale: An appropriate size cuff should have at least 80 percent of the cuff encircling the arm therefore using a blood pressure cuff that encircles the arm by 60 percent would increase the risk of an inaccurate measurement. The other choices would not increase the risk of an inaccurate measurement.
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The nurse is assessing the eyes of an older adult client. Which finding is expected by the nurse based on the client's age?
1. The client is easily able to read from a paper held at close range without corrective glasses. 2. There is a noticeable increase in fat within the orbit of the eye. 3. The client states that she feels her tear production has increased over the years. 4. The pupillary light reflex is slower bilaterally.
What should the nurse include when explaining endometriosis as a cause for a female patient's infertility?
A) "You do not ovulate because of endometrial implants on the ovaries.". B) "Your uterine cervix fails to close because it is engorged with tissue.". C) "Menstrual sloughing does not occur, so there is never a new base for embryo growth.". D) "Ovulation does take place misplaced endometrial tissue interferes with transport of the ovum.".
Infusion pumps rely on pressure to infuse fluids. You must monitor the infusion site regularly for signs of
infiltration. Indicate whether the statement is true or false
Despite having high BP readings in the office, Mr. Kelly tells you that his readings at home are much lower. He checks them twice a day at the same time of day and has kept a log. How do you respond?
A) You diagnose “white coat hypertension.” B) You assume he is quite nervous when he comes to your office. C) You question the accuracy of his measurements. D) You question the accuracy of your measurements.