The nurse has assigned nursing assistive personnel to obtain the ...

[imowrer]

The nurse has assigned nursing assistive personnel to obtain the temperatures on the unit's clients.
 
  Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate temperature monitoring orally?
  1. Are all the clients cooperative enough to take the temperatures orally?
  2. Do you want me to take the temperature tympanically on everyone?
  3. I'll wait until breakfast is over so I won't distract them from eating.
  4. I'll chart the results and let you know whose temperature is running high.

Question 2

The nurse is using a manual cuff to assess the blood pressure of a client experiencing hyperten-sion.
 
  To best ensure accommodation for a possible auscultatory gap, the nurse should use which of the following as a guide for inflating the cuff appropriately?
  1. Review the client's chart for his last blood pressure reading.
  2. Ask the client what his typical blood pressure reading is when taken manually.
  3. Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated.
  4. Take the client's blood pressure both sitting and standing and use the higher reading.

[Ddddd]

Answer to Question 1

ANS: 3
When taking oral temperature, wait 20 to 30 min before measuring temperature if the client has smoked or ingested hot or cold liquids or foods. The nurse needs to reinforce this information so that the assessment will occur before breakfast or to allow enough time to pass after breakfast so as not to affect the readings. The options containing a question reflect a need for knowledge but do not have priority over an obvious indication of possible poor assessment technique. The nurse needs to evaluate the readings and so should be sure to give the assistive personnel guidance as to what readings are running high.

Answer to Question 2

ANS: 3
The examiner needs to be certain to inflate the cuff high enough to hear the true systolic pressure before the auscultatory gap. Palpation of the radial artery helps to determine how high to inflate the cuff. The examiner inflates the cuff 30 mm Hg above the pressure at which the radial pulse was palpated. Taking the blood pressure in various positions will not help eliminate the possible loss of auditory sound between the systolic and diastolic sounds. While asking the client and/or reviewing the chart may provide information concerning the client's pressure, these options are not the recommended method for minimizing the effect of the auditory gap on the assessment process.

[imowrer]

Excellent

[nguyenhoanhat]

TYSM