The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which of the following actions?
A) Measuring the BP after the patient has been seated quietly for more than 5 minutes
B) Taking the BP at least 10 minutes after nicotine or coffee ingestion
C) Using a cuff with a bladder that encircles at least 80% of the limb
D) Using a bare forearm supported at heart level on a firm surface
Ans: B
Feedback:
Blood pressures should be taken with the patient seated with arm bare, supported, and at heart level. The patient should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The patient should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured and have a width of at least 40% of limb circumference. Using a cuff that is too large results in a lower BP and a cuff that is too small will give a higher BP measurement.
You might also like to view...
A nurse is looking at photographs of a friend's infant. The nurse notes a whitish glow in the child's eyes, and the friend asks why the baby's eyes look so odd. Which response by the nurse is the most appropriate?
A. "If his eyes look like this by 6 months, he needs to see a doctor." B. "Take him to the doctor to see what's wrong with his eyes." C. "This is called leukocoria and may signify retinoblastoma." D. "Your baby may have a brain tumor; take him to the hospital."
The population health nurse is teaching a group of community members on women's reproductive health. Which client statement indicates teaching has been effective?
1. "Perimenopause occurs after menopause." 2. "Menopause typically occurs after the third pregnancy." 3. "The potential for childbearing is high during premenopause." 4. "Postmenopause occurs over a period of approximately three years."
The nurse is caring for a patient receiving long-term glucocorticoid therapy. Upon assessment, the nurse notes that the patient has 1+ pitting edema of the lower extremities
What instruction provided by the nurse would be most appropriate for this patient? a. "Augment your diet with calcium supplements." b. "Restrict your sodium intake." c. "Take the glucocorticoid every 3 to 4 days instead of daily." d. "Discontinue the glucocorticoid."
A diabetic client has a large wound on his right leg that has not healed in 5 months. At the first visit, the nurse should assess
A) wound care orders, cleaning methods, supportive devices, and dietary restrictions. B) activity order restrictions and wound care orders. C) mobility and pain. D) routine assessment information.