Author Question: A nurse is required to document an adult client's blood pressure. Which nursing intervention will ... (Read 43 times)

jake · **on:** Jul 17, 2018

A nurse is required to document an adult client's blood pressure. Which nursing intervention will help ensure that the systolic reading is not underestimated?

A) Assist the client to a comfortable position before assessing the pressure.
B) Center the cuff's bladder above the site where the brachial pulse is palpated.
C) Check that the aneroid manometer is vertical and at eye level.
D) Inflate the cuff to a pressure 30 mm Hg above the point where the pulse disappears.

Question 2

The nurse is assisting in performing a viral load (HIV-RNA) test to measure how virulent the HIV is in a client diagnosed with AIDS. Which of the following information regarding this testing is accurate?

A) A person who is not infected with HIV has a minimum viral load.
B) Clients with controlled HIV may have readings as high as 1,000,000 copies.
C) An undetectable reading is considered an excellent response to therapy.
D) The inability to detect the virus in the blood indicates a person is no longer infected.

yasmin · **Reply #1 on:** Jul 17, 2018

Answer to Question 1

D
Feedback:
Inflating the cuff to a pressure 30 mm Hg above the point where the pulse has disappeared, after closing the screw clamp on the bulb, helps ensure that the systolic reading is not underestimated. Assisting the client to a comfortable position helps to foster cooperation. Centering the cuff's bladder approximately 1 inch above the site where the brachial pulse has been palpated helps ensure even cuff inflation over the brachial artery. A mercury manometer needs to be at eye level because improper height can alter perception of reading. However, this does not apply to an aneroid manometer.

Answer to Question 2

C
Feedback:
The HIV-RNA, or viral load, is measured to determine how virulent the virus is. A person who is not infected with HIV has an undetectable viral load. An undetectable reading is also considered to be an excellent response to therapy, although the inability to detect the virus in the blood does not indicate that a person is no longer infected. Clients with HIV that is not controlled with medications may have readings as high as 1,000,000 copies or more of viral cells read as viral load.