Nokea
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
- A. Wrap the blood pressure cuff snugly around the arm.
- B. Place the client's arm above the level of the heart.
- C. Check the instrument gauge to ensure the reading starts at zero.
- D. Center the cuff bladder over the brachial artery.
Correct Answer: B
Rationale: The correct answer is B because placing the client's arm above the level of the heart can result in an inaccurate blood pressure reading. Ideally, the arm should be at heart level to obtain an accurate measurement. A: Wrapping the cuff snugly ensures an accurate reading. C: Checking the gauge for zero ensures proper calibration. D: Centering the cuff bladder over the brachial artery is correct for accurate measurement. Overall, maintaining the arm at heart level is crucial to obtaining an accurate blood pressure reading.
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A nurse is caring for a client who has dyspnea, crackles, and 3+ bilateral pitting pedal edema. Which of the following serum sodium levels should the nurse identify as an indication of fluid volume excess?
- A. 116 mEq/L
- B. 136 mEq/L
- C. 142 mEq/L
- D. 167 mEq/L
Correct Answer: A
Rationale: The correct answer is A (116 mEq/L). A low serum sodium level indicates dilutional hyponatremia, which can occur in fluid volume excess. In this case, the client's symptoms of dyspnea, crackles, and pedal edema point towards fluid overload. A serum sodium level of 116 mEq/L reflects dilution due to excess fluid in the body, indicating fluid volume excess. Choices B, C, and D have normal to high sodium levels, which do not correlate with fluid volume excess. Therefore, A is the most appropriate choice based on the client's clinical presentation.
A nurse is caring for a client who requires a clear liquid diet. Which of the following foods should the nurse allow the client to have?
- A. Grape juice
- B. Lemon sherbet
- C. Skim milk
- D. Carrot juice
Correct Answer: A
Rationale: The correct answer is A: Grape juice. A clear liquid diet includes transparent liquids like water, broth, tea, and clear juices without pulp. Grape juice fits this criteria as it is a clear liquid that is easily digestible. Lemon sherbet (B) contains dairy and solid components, not suitable for a clear liquid diet. Skim milk (C) is a dairy product and not transparent. Carrot juice (D) has pulp and is not considered a clear liquid.
A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?
- A. Cool skin
- B. Numbness
- C. Pallor
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. Thrombophlebitis is inflammation of a vein with a blood clot, leading to impaired blood flow. Edema, or swelling, is a common symptom due to the obstruction of blood flow. This results in fluid accumulation in the affected area. Cool skin, numbness, and pallor are not typical findings in thrombophlebitis. Cool skin and numbness are more indicative of nerve or circulation issues, while pallor suggests reduced blood flow but is not a common finding in thrombophlebitis.
When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?
- A. Wrapping the cuff too loosely around the client's arm
- B. Positioning the client's arm above heart level
- C. Measuring blood pressure right after the client's mealtime
- D. Deflating the cuff too slowly
Correct Answer: B
Rationale: The correct answer is B: Positioning the client's arm above heart level. When the client's arm is positioned above heart level, it can lead to an artificially low blood pressure reading due to gravitational effects. This position can cause blood to pool in the arm, reducing the pressure in the arteries and resulting in an inaccurate measurement. This error is known as hydrostatic pressure error. Wrapping the cuff too loosely (choice A) can lead to an inaccurate reading due to inadequate compression of the artery. Measuring blood pressure right after a meal (choice C) can also affect the reading due to the body's response to food intake. Deflating the cuff too slowly (choice D) can result in a falsely elevated diastolic reading.
A nurse is performing wound care for an older adult client who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?
- A. Transparent
- B. Wet-to-dry
- C. Dry, sterile
- D. Antimicrobial
Correct Answer: A
Rationale: Transparent dressings protect stage I pressure ulcers while allowing for visualization of the wound.