8. A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take? Chapter 27 Vitals signs page
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a. Apply the cuff above the client‟s antecubital fossa.
b. Use a cuff with a width that is about 60% of the client's arm circumference. - width of the cuff should be 40 % of arm circumference
c. How the clients sit with his arm resting above the level of his heart. - MUST BE AT HEART LEVEL
d. Release the pressure on the client's arm 5 to 6 mm per second. - pressure release should not be more than 2 to 3 mm hg per second
Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the pressure no faster than 2 to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff.Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff.
9. A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take? Chapter 53 Airway management page 563
a. Hold the suction catheter with the clean non-dominant hand.
b. Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum.
c. Place the catheter in a location that is clean and dry for later use new line.- NEVER EVER REUSE THE SUCTION CATHETER . you throw it away after being used.
d. Use surgical asepsis when performing the procedure.- book say medical asepsis which is maybe the same thing .
Rationale: sterile technique for trachea
Rationale: ATI FUNDA. PG. 316 Use surgical asepsis for all types of suctioning. No longer than 10-15 seconds to avoid hypoxemia
10. A nurse is documenting client care. Which of the following abbreviations should the nurse use?ati book was not thorough so i had to go on different sites for charts - not confident with this, please double check.
a. “SS” for sliding scale
b. “BRP” for bathroom privileges
c. “OJ” for orange juice- do not
d. “SQ” for subcutaneous- do not
11. MISSING
12. A nurse is collecting A blood pressure reading from a client who is sitting in a chair period the nurse determines that the clients BP is 158/96 mmhg. which of the following actions should the nurse take?
a. Ensure that the width of the BP cuff is 50% of the client‟s upper arm circumference. It says 40%
b. Reposition the client Supine and recheck her BP. BP. → ORTHOSTATIC HYPOTENSION
c. Recheck the clients BP and her other arm for comparison.
d. Request that another nurse check the the clients BP in 30 minutes. → 15 minutes
13. A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage? Chapter 53 Airway Management page 562
e. Supine and low-Fowler's position
f. Right lateral in Trendelenburg position
g. Side lying with the right side of the chest elevated
h. Prone with pillows under the extremities [Show Less]