what is the proper technique for measuring a patients blood pressure

ATI LPN

ATI PN Comprehensive Predictor

1. What is the proper technique for measuring a patient's blood pressure?

A. Place the cuff at heart level and listen for Korotkoff sounds
B. Ensure the patient is in a seated position and inflate the cuff to 180 mmHg
C. Use a manual sphygmomanometer and measure blood pressure on both arms
D. Monitor pulse rate and apply pressure to the brachial artery

Correct answer: A

Rationale: The correct technique for measuring blood pressure involves placing the cuff at heart level to ensure accurate readings. Listening for Korotkoff sounds helps determine the systolic and diastolic pressures. Choice B is incorrect as inflating the cuff to 180 mmHg is excessive and can lead to inaccurate readings. Choice C is incorrect as it is unnecessary to measure blood pressure on both arms unless there is a specific medical reason to do so. Choice D is incorrect as monitoring pulse rate and applying pressure to the brachial artery are not part of the standard blood pressure measurement technique.

2. Which of the following is a key consideration when providing wound care for a client with a pressure ulcer?

A. Cover the wound with a dry, sterile dressing
B. Perform a wound culture before applying ointment
C. Cleanse the wound with alcohol
D. Cover the wound with a wet-to-dry dressing

Correct answer: B

Rationale: Performing a wound culture before applying ointment is crucial when providing wound care for a client with a pressure ulcer. This step helps identify the presence of any infection, allowing for appropriate treatment. Choice A is incorrect because covering the wound with a dry, sterile dressing may not address potential infections. Choice C is incorrect as cleansing the wound with alcohol can be too harsh and drying to the surrounding skin. Choice D is incorrect because covering the wound with a wet-to-dry dressing is not typically recommended for pressure ulcers, as it can cause trauma to the wound bed during removal.

3. The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client?

A. Facilitate the client in returning to usual activities of daily living
B. Maintain optimal function within the client's limitations
C. Assist the client in preparing for a peaceful and dignified death
D. Delay the progression of the disease process in the client

Correct answer: B

Rationale: Maintaining optimal function within the client's limitations is the most realistic and appropriate nursing goal when caring for an 80-year-old client with Parkinson's disease. This goal focuses on maximizing the client's abilities and quality of life while acknowledging the impact of the disease. Option A is less realistic as returning to usual activities may not always be achievable in the case of Parkinson's disease. Option C is not appropriate as it does not address the client's current condition and care needs. Option D is less realistic as Parkinson's disease is progressive, and delaying its progression may not be entirely feasible.

4. A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?

A. The roommate is up independently
B. The client ambulates with his slippers on over his antiembolic stockings
C. The client uses a front-wheeled walker when ambulating
D. The client had pain meds 30 minutes ago

Correct answer: C

Rationale: The correct answer is C. After knee arthroplasty, it is essential for the client to use a front-wheeled walker when ambulating to ensure stability and prevent falls. Sharing this information with the assistive personnel (AP) is crucial for the client's safety and proper rehabilitation. Choices A, B, and D are incorrect because the roommate's independence, the client's footwear over stockings, and the timing of pain medication administration are not directly related to the safe ambulation of a client post-knee arthroplasty.

5. What are the key interventions for managing pneumonia?

A. Administer antibiotics and monitor oxygen levels
B. Administer bronchodilators and encourage deep breathing
C. Provide fluids and monitor for dehydration
D. Administer oxygen and provide bed rest

Correct answer: A

Rationale: The correct answer is A: Administer antibiotics and monitor oxygen levels. Antibiotics are essential to treat the infection caused by bacteria in pneumonia, while monitoring oxygen levels helps ensure adequate oxygenation. Administering bronchodilators and encouraging deep breathing, as in choice B, are more commonly associated with managing conditions like asthma or COPD, not pneumonia. Providing fluids and monitoring for dehydration, as in choice C, are important for various conditions but not specific to pneumonia management. Administering oxygen and providing bed rest, as in choice D, may be supportive measures in pneumonia treatment, but the key intervention is administering antibiotics.