ATI LPN Funsamentals Exam V

Extract:

Spouse of a client learning to take blood pressure

Question 1 of 5

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

A. Wrap the blood pressure cuff snugly around the arm.B. Center the cuff bladder over the brachial artery.C. Place the client's arm above the level of the heart.D. Check the instrument gauge to ensure the reading starts at zero

Correct Answer: C

Rationale: Placing the arm above heart level (
C) leads to falsely low readings. Snug cuff (
A), brachial artery placement (
B), and zero gauge (
D) are correct techniques.

Extract:

Question 2 of 5

If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

A. pulse deficitB. diastolicC. auscultatory gapD. widened pulse pressure

Correct Answer: C

Rationale: An auscultatory gap (
C) is silence between Korotkoff sounds, indicating possible arterial stiffness. Pulse deficit (
A) compares pulses, diastolic (
B) is a pressure phase, and widened pulse pressure (
D) is the systolic-diastolic difference.

Extract:

45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular)

Question 3 of 5

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

A. check the patient's record to determine his baseline blood pressure.B. notify the charge nurse of the hypotension.C. check medications that might be the cause of the irregularity.D. notify the doctor of the bradycardia.

Correct Answer: A

Rationale: Checking baseline blood pressure (
A) verifies if 98/66 mm Hg is normal for the patient. Hypotension notification (
B) is premature, medications (
C) are secondary, and 76 beats/min isnâ€™t bradycardia (
D).

Extract:

Question 4 of 5

The nurse taking a blood pressure should:

A. place the arm so that the brachial artery is at waist level.B. chat with the patient to reduce any anxiety in the patient.C. request that the patient put feet flat on the floor.D. position the patient so that the arm is level with the shoulder.

Correct Answer: C

Rationale: Feet flat on the floor (
C) stabilizes posture for accurate readings. Waist level (
A) or shoulder level (
D) alters pressure, and chatting (
B) may distract from auscultation.

Question 5 of 5

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

A. After palpating the abdomenB. Prior to percussing the abdomenC. After checking for kidney tendernessD. Prior to inspecting the abdomen

Correct Answer: B

Rationale: Auscultating before percussion (
B) avoids altered sounds from manipulation. Palpation (
A), kidney checks (
C), or inspection (
D) may disrupt natural bowel sounds if done first.

ATI LPN Funsamentals Exam V | Nurselytic

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