Which action should the nurse take to ensure that a client's ...

[jerry coleman]

Which action should the nurse take to ensure that a client's blood pressure is accurately measured? (Select all that apply.)
 
  1. Place the cuff bladder over the artery.
  2. Measure the blood pressure on both arms.
  3. Use a cuff that is 40 of the arm circumference.
  4. Deflate the cuff at the rate of 2 to 3 mm Hg per second.
  5. Note the diastolic reading when the first tapping sound is heard.

Question 2

A client being discharged following treatment for a deep venous thrombosis (DVT) will be taking warfarin (Coumadin) at home. What should the nurse instruct this client?
 
  1. Avoid drinking any alcohol while taking this med.
  2. If you miss a dose of the drug, wait until the next day to take the next dose.
  3. Include a lot of dark green, leafy vegetables in your diet.
  4. Use over-the-counter anti-inflammatory drugs for pain or a headache.

[Tonny]

Answer to Question 1

Answer: 1, 2, 3, 4

1. To ensure an accurate blood pressure measurement the nurse should place the cuff bladder over the artery.
2. To ensure an accurate blood pressure measurement the nurse should measure the blood pressure on both arms.
3. To ensure an accurate blood pressure measurement the nurse should use a cuff that is 40 of the arm circumference.
4. To ensure an accurate blood pressure measurement the nurse should deflate the cuff at the rate of 2 to 3 mm Hg per second.
5. To ensure an accurate blood pressure measurement the nurse should note the systolic reading when the first tapping sound is heard.

Answer to Question 2

Answer: 1

1. Alcohol interacts with Coumadin, and can prolong bleeding times.
2. If a dose is missed, the pill should be taken as soon as possible.
3. Green, leafy vegetables are high in vitamin K, and will prolong bleeding times with Coumadin.
4. ASA and NSAIDs interact with Coumadin, and can prolong bleeding times.