The nursing student is practicing blood pressure skills at a ...

[ghost!]

The nursing student is practicing blood pressure skills at a screening clinic. After taking a client's blood pressure several times, the student tells the instructor that the Korotkoff's sounds cannot be heard.
 
  Prior to the instructor's measuring blood pressure, the nurse should do which of the following to improve accuracy? 1. Have the instructor apologize to the client for repeated cuff inflation.
  2. Have the client pump his fist to improve volume of Korotkoff's sounds.
  3. Move the cuff to the other arm.
  4. Have the client elevate his arm.

Question 2

The nurse is caring for an adolescent who is quadriplegic following an accident and who will require rehabilitation after discharge from the acute care facility. The nurse encourages placement in a facility that:
 
  1. Is as close to the teen's home as possible.
  2. Allows the teen to be placed on a unit with peers.
  3. Has a lower cost for treatment.
  4. Cares for only children.

[Animal_Goddess]

Answer to Question 1

3
Rationale: Repeated inflation of the cuff causes false elevation of blood pressure due to repeated engorgement of the artery. The cuff should be moved to the other arm before performing another measurement. The student should have been the one to apologize to the client, and fist pumping will not alter Korotkoff's sounds, although it could have an adverse effect on accuracy of the measurement. Blood pressures should be measured with the brachial pulse at heart level, and elevation of the arm will create a falsely low reading.

Answer to Question 2

2
Rationale: Rehabilitation in a facility accustomed to caring for adolescents that will allow the teen to interact with peers will be of greatest benefit, and will improve outcome for the client.