Question

Which of the following statements made by the nurse will be most effective in instructing the student nurse regarding the appropriate technique for measuring the adult patient’s blood pressure?

a.

“You need to wait 20 - 30 seconds before re-measuring the blood pressure on the same arm.”

b.

“Record the fifth Korotkoff sound as the patient’s systolic pressure.”

c.

“Inflate the cuff an additional 30 mm Hg above where the pulse disappears.”

d.

“The size of the cuff will not affect the result in adults.”

A client is diagnosed with Methicillin Resistant Staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client?

a.

Standard precautions

b.

Reverse

c.

Airborne

d.

Contact

The nurse is aware that pulse pressure is which of the following?

a.

The strength of the radial pulse on palpation

b.

The difference between the systolic and diastolic reading

c.

The Loudest sound of the heart

d.

The difference between the radial and apical pulse

Which of the following patient’s is at greatest risk for developing adverse effects of immobility?

	a.	A 3-year-old child with a fractured femur (leg)
	b.	A 78-year-old man admitted after a cerebrovascular accident (stroke)
	c.	A 12-year-old boy with a broken arm
	d.	A 38-year-old woman post-appendectomy (appendix removal)

Answer 1

First Question Answer: Inflate the cuff an additional 30mmHg above where the pulse disappears

All other options are wrong technique related to blood pressure assessment.

Second question Answer: contact isolation

Contact isolation is used in the case of infection or disease that can be spread through touching the patient or the items in the room. The other conditions required  of contact isolation include VRE, diarrheal disease, open wound,RSV.

Health workers should wear gown and gloves while caring the patient with contact isolation.

Third question Answer: the difference between the systolic and diastolic reading

Pulse pressure is the force generated by the heart when it contracts each time. Normal pulse pressure for an adult is approximately 40mmHg. Measuring pulse pressure can help to detect the risk of heart attack and stroke. If pulse pressure is more than 60mmHg,it is a risk factor for cardiovascular disease in older adults.

Fourth question Answer: A 78 years old man admitted after a cerebrovascular accident

Among the above mentioned examples 78yrs old man with stroke will be having more difficult for moving by himself due to weakness associated with stroke. So he will be more prone to get immobility related problems like pressure ulcer. So frequent position change is recommended for such patients.