The nursing student is learning about the appropriate method to use when assessing a client's blood pressure. The student nurse asks the nursing instructor why it is necessary to palpate the systolic pressure prior to the procedure
Which of the following is the nursing instructor's best response? 1. "You can document this value if you cannot hear the blood pressure well.".
2. "This needs to be done only when the client is developing clinical manifestations associated with shock.".
3. "You are more likely to get an accurate reading when you do it this way.".
4. "It is the best way to determine an arterial obstruction.".
3
Rationale 1: It is not appropriate to merely document the palpable systolic pressure. Efforts should be made to document the client's blood pressure.
Rationale 2: When a client is developing clinical manifestations associated with shock, his blood pressure is more likely to be lower than normal. The nurse should palpate the systolic pressure for all clients regardless of their diagnoses.
Rationale 3: Assessing the palpable systolic pressure helps to avoid inaccuracy in blood pressure assessment that can occur with an ausculatory gap, or space in which beats are not heard, during this assessment.
Rationale 4: This can be assessed by measuring the difference between the blood pressures in the arms. A difference of 10 mm Hg or more between the arms may indicate an obstruction of arterial flow to one arm.
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The nurse working in the emergency clinic admits a minor requiring immediate treatment for a life-threatening condition. The nurse calls the minor's home and finds the parents at home. The best course of action for the nurse is to:
1. Have the parents rush to the Emergency Department. 2. Have the parents fax written consent. 3. Have another nurse listen on the phone to document verbal consent. 4. Call the hospital's Legal Department to obtain consent from the parents.
When performing a screening for critical congenital heart disease (CCHD), where should the nurse obtain the preductal pulse oximeter reading?
A) From the right hand B) From the left hand C) From the right foot D) From the left foot
A patient complains that sometimes there appears to be gnats in the field of vision. The nurse would interpret this statement to mean that the patient has which visual change?
1. Conjunctivitis 2. Floaters 3. Strabismus 4. Nystagmus
The nurse is caring for a patient in the prenatal clinic. The patient recently arrived in the United States as a refugee from a country in Africa. This is the first patient from this cultural background with whom the nurse has worked
Which intervention is most appropriate in the care of this patient? 1. Ask the patient about her expectations during the labor and birth. 2. Determine if the patient has been tested for tuberculosis. 3. Help the patient into the paper dressing gown prior to her exam. 4. Look for written handouts on prenatal care in the patient's language.