The nurse is assessing a client's blood pressure. The client asks ...

[jilianpiloj]

The nurse is assessing a client's blood pressure. The client asks the nurse why it is important to feel for his pulse prior to taking his blood pressure. Which response by the nurse is the most appropriate?
 
  1. I can document this value if I am unable to measure your blood pressure the other way.
  2. I need to feel for your pulse because you doctor said you are developing symptoms of shock.
  3. I am more likely to get an accurate reading if I do it this way.
  4. It is the best way to determine an arterial obstruction.

Question 2

The nurse is performing an assessment of the client's peripheral vascular system. Which actions by the nurse are appropriate when assessing this client?
 
  1. Assessing the client in a flat, supine position when the client exhibits a respiratory rate of 26 breaths/min. with a dusky appearance around the mouth and lips.
  2. Requesting the client remove all undergarments prior to putting the gown.
  3. Assessing pedal pulses over the client's socks.
  4. Taking a blood pressure cuff, Doppler, and stethoscope into the client's room for the assessment.

[frejo]

Answer to Question 1

Correct Answer: 3
Assessing the palpable systolic pressure helps to avoid inaccuracy in blood pressure assessment that can occur with an ausculatory gap, or space in which beats are not heard, during this assessment. It is not appropriate to merely document the palpable systolic pressure. Efforts should be made to document the client's blood pressure. When a client is developing clinical manifestations associated with shock, his blood pressure is more likely to be lower than normal. The nurse should palpate the systolic pressure for all clients regardless of their diagnoses. Arterial obstruction can be assessed by measuring the difference between the blood pressures in the arms. A difference of 10 mmHg or more between the arms may indicate an obstruction of arterial flow to one arm.

Answer to Question 2

Correct Answer: 4
A blood pressure cuff, Doppler, and stethoscope are appropriated pieces of equipment for the nurse to bring into the room for the assessment of this client. The student nurse must pay attention to how well the client tolerates the various positions during the assessment. The client needs to remove only socks and shoes prior to putting on the gown. The socks must be removed to accurately assess the peripheral vascular system.

[jilianpiloj]

Thank you

[frejo]

Happy to help you