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. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include?

A. Document the client's condition every 15 minutes.
B. Attach the restraints to a non-moving part of the bed.
C. Avoid requesting a PRN restraint prescription for clients who are aggressive.
D. Remove the client's restraints based on the client's condition.

Correct answer: A

Rationale: The correct answer is A: Document the client's condition every 15 minutes. When using belt restraints, it is crucial to document the client's condition regularly to ensure their safety and well-being. This guideline allows for ongoing assessment of the client's need for restraints and any potential adverse effects. Choice B is incorrect as restraints should not be attached to the bed frame but to a non-moving part of the bed to prevent harm in case of bed movement. Choice C is incorrect as PRN (as needed) restraint prescription should not be a routine practice and should only be considered after other interventions have been attempted. Choice D is incorrect as restraints should be removed and reevaluated based on the client's condition, not solely on a fixed time schedule.

3. What are the differences between viral and bacterial infections?

A. Viral infections often cause fatigue and body aches
B. Bacterial infections often cause high fever and localized pain
C. Viral infections are treated with antibiotics
D. Bacterial infections are usually self-limiting

Correct answer: A

Rationale: Corrected Rationale: Viral infections often cause fatigue and body aches, while bacterial infections are more likely to cause high fever and localized pain. Choice A is the correct answer as it accurately reflects the symptoms commonly associated with viral infections. Bacterial infections, on the other hand, typically present with fever and localized pain, as stated in choice B. Choice C is incorrect as viral infections do not respond to antibiotics, while choice D is inaccurate because bacterial infections may require antibiotic treatment and are not always self-limiting.

4. What is the nurse's priority when caring for a client with a tracheostomy who is showing signs of respiratory distress?

A. Administer a bronchodilator
B. Suction the tracheostomy
C. Notify the physician immediately
D. Increase the oxygen flow rate

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy. When a client with a tracheostomy is experiencing respiratory distress, the priority intervention is to clear the airway by suctioning the tracheostomy to remove secretions that may be obstructing the air passage. Administering a bronchodilator (Choice A) may be considered if bronchospasm is present, but the immediate focus should be on clearing the airway. Notifying the physician (Choice C) is important but should not delay the immediate intervention of suctioning. Increasing the oxygen flow rate (Choice D) may provide temporary relief, but addressing the root cause of the distress by suctioning is the priority.

5. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
B. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.
C. A client who has epidural analgesia and weakness in the lower extremities.
D. A client who has a hip fracture and a new onset of tachypnea.

Correct answer: D

Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.