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 is teaching a client who has chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following instructions should the nurse include?

A. Use abdominal breathing during physical activity
B. Inhale quickly and deeply through the nose
C. Use pursed-lip breathing during physical activity
D. Breathe quickly and deeply during exercise

Correct answer: C

Rationale: The correct answer is C: 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a beneficial technique for clients with COPD as it helps improve airflow by keeping the airways open longer. Choice A is incorrect as abdominal breathing may not be as effective in COPD as pursed-lip breathing. Choice B, inhaling quickly and deeply through the nose, is not recommended as it can lead to hyperventilation. Choice D, breathing quickly and deeply during exercise, is also not suitable for clients with COPD as it can cause increased shortness of breath.

3. What lifestyle change should be emphasized for a client with hypertension?

A. Increase intake of dairy products
B. Reduce caffeine and sodium intake
C. Eat carbohydrate-rich meals
D. Limit intake of leafy green vegetables

Correct answer: B

Rationale: The correct lifestyle change that should be emphasized for a client with hypertension is to reduce caffeine and sodium intake. Caffeine can temporarily raise blood pressure, and high sodium intake is linked to increased blood pressure levels. Therefore, reducing these two components can help manage blood pressure in individuals with hypertension. Choices A, C, and D are incorrect because increasing intake of dairy products, consuming carbohydrate-rich meals, and limiting intake of leafy green vegetables do not specifically address the factors that contribute to high blood pressure in hypertension.

4. A nurse in the emergency department is caring for a client who has full-thickness burns of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?

A. Providing pain management.
B. Offering emotional support.
C. Preventing infection.
D. Initiating IV fluids.

Correct answer: D

Rationale: After securing the airway, initiating IV fluids is the priority to prevent hypovolemic shock in clients with severe burns. IV fluids help maintain circulating volume and prevent a drop in blood pressure due to fluid loss. Providing pain management, offering emotional support, and preventing infection are important aspects of care but are secondary to ensuring adequate fluid resuscitation in clients with severe burns.

5. What is the priority when managing a client with a chest tube postoperatively?

A. Clamp the chest tube for 30 minutes every 4 hours
B. Check for air leaks and proper functioning of the chest tube
C. Encourage deep breathing and coughing every 2 hours
D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The priority when managing a client with a chest tube postoperatively is to check for air leaks and ensure the proper functioning of the chest tube. This is crucial to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube intermittently can lead to a buildup of pressure in the pleural space and should not be done without a specific medical indication. Encouraging deep breathing and coughing helps with lung expansion but is not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing may increase the risk of dislodging the chest tube or causing complications.