Exam 1- Preclinical

The nurse is preparing to measure an adult's orthostatic blood pressure. Place the following steps of the procedure in the correct order.

1)Assist the client into a supine position. 2)Wait 3 to 10 minutes, then measure the client's blood pressure. 3)Assist the client to the sitting position with legs dangling. 4)Wait 1 to 3 minutes, then measure the client's blood pressure. 5)Assist the client to a standing position. 6)Wait 2 to 3 minutes, then measure the client's blood pressure.

The nurse estimates a client's systolic pressure to be 150 mm Hg. When obtaining the client's blood pressure measurement with a sphygmomanometer, the nurse would inflate the cuff to which pressure?

30mmHg above, so 180mmHg

What is most important for the nurse to do when using an automatic electronic device to obtain serial blood pressure readings?

Check that the cuff is deflated completely after the reading. (so as to maintain arterial perfusion and circulation)

1The nurse is obtaining serial blood pressure measurements on a client having hypertension medication adjustment. What assessment is most important for the nurse to perform frequently?

Determine if there is compromised circulation in the limb.

The nurse reads the client's history and notes the client has vascular insufficiency in one upper extremity and both lower extremities. Which device would be most appropriate for assessing the client's blood pressure?

Doppler Ultrasound venous insufficiency makes it hard to hear the sound

The nurse obtains a blood pressure on a client using a Doppler ultrasound device but is unsure if the results are accurate. The nurse plans to repeat the measurement. What step would the nurse take to ensure a correct reading?

Ensure that the cuff is completely deflated before attempting another reading. It is important to wait at least 1 minute between readings to allow normal circulation to return to the limb

When using a Doppler to obtain a client's blood pressure, which action does the nurse take?

Inflate the cuff until the pulse disappears. Only a systolic blood pressure can be obtained via ultrasound. The systolic number is determined by the occlusion and absence of the brachial pulse.

The nurse prepares for a sterile procedure. What action does the nurse perform first?

Perform hand hygiene with alcohol-based handrub. before you even walk into the room and identify the patient.

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply.

Press and rotate the swab several times over the wound surfaces., Insert a swab into the wound., Place the swab in the culture tube when done.

The client is experiencing a neuromuscular condition with frequent tremors. The nurse determines to manually check the client's blood pressure instead of using the electronic blood pressure machine. What is the rationale behind the nurse's decision?

The blood pressure machine would not be accurate. Electronic blood pressure devices are not recommended for clients with irregular heart rates, tremors, and the ability to hold the extremity still. The presence of these conditions may cause the monitor to incorrectly overinflate the cuff, causing pain for the client. The client's comfort and position are not as important as the accuracy of the reading. The nurse's preference is not a priority.

When preparing to measure orthostatic hypotension, the nurse should place the bed in which position?

The lowest position Rationale:When measuring for orthostatic hypotension, lower the head of the bed to a flat position. Position the bed in the lowest position so that when client sits, up the feet can be placed on the floor and the lowest position allows for easier standing. This position also allows for maximum standing and an easier way to get the client back in bed if hypotension should occur.

A client's blood pressure is very low and the nurse needs to asses it using a Doppler. To get an accurate reading the nurse would inflate the cuff to what level on the manometer?

Where the pulse disappears

A nurse is measuring a client's blood pressure using an electronic device. What is important for the nurse to do to ensure accurate results?

irregular heart rate, excessive client movement, and environmental noise can interfere with the accuracy of the readings obtained with an electronic blood pressure device

The nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What should the nurse do next?

the nurse should cleanse the wound with a nonantimicrobial cleanser to prevent the culture from being contaminated by extraneous wound debris.

The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure?

to obtain a wound culture, the nurse would first clean the wound, then obtain the wound culture, redress the wound, and document the procedure when complete. Cleaning the wound removes previous drainage and wound debris, which could introduce extraneous organisms into the collected specimen, resulting in inaccurate results.