Exam Cram NCLEX RN Practice Questions - Nurselytic

Correct Answer: C

Rationale: When measuring blood pressure, it's important to account for the possibility of an auscultatory gap, which occurs in about 5% of individuals, particularly those with hypertension due to a noncompliant arterial system.
To detect an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears. This ensures an accurate measurement of blood pressure by overcoming the potential gap in sounds.
Choice A is correct as it follows this guideline.

Choices B and C are incorrect because inflating the cuff to 200 mm Hg or above the patient's pulse rate does not address the specific issue of an auscultatory gap.
Choice D is incorrect as it focuses on the patient's previous readings rather than the current measurement technique needed to detect an auscultatory gap.

Correct Answer: A

Rationale:
To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes.
Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate.
Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort.
Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.

Correct Answer: C

Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.

Correct Answer: B

Rationale: Pulse pressure is the numerical difference between the systolic and diastolic blood pressure readings. In this case, the systolic blood pressure is 170 mm Hg, and the diastolic blood pressure is 100 mm Hg.
Therefore, the pulse pressure is calculated as 170 - 100 = 70 mm Hg. Pulse pressure reflects the stroke volume, the amount of blood ejected from the heart with each beat.

Choices A, C, and D are incorrect because they do not accurately represent the difference between the systolic and diastolic blood pressure readings provided.

Correct Answer: D

Rationale: When measuring a patient's weight, it is important to ensure accuracy and consistency. If a sequence of repeated weights is necessary, the healthcare professional should attempt to weigh the patient at the same time of day and with the same types of clothing worn each time. It is crucial to use a standardized balance or electronic standing scale for accurate weight measurement.
Choice A is incorrect as patients should remove heavy outer clothing, shoes, and jackets before being weighed for accurate results.
Choice B is incorrect because the type of scale used does matter and should be consistent for reliable weight tracking.
Choice C is incorrect as patients should not leave on heavy outer clothing, shoes, or jackets as these items can add to the weight recorded inaccurately.