Practice Question
A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?
Answer Choices:
Correct Answer:
The site where the blood pressure was obtained.
Rationale:
🔹Documenting the site (e.g., right arm, left forearm, thigh) is crucial because blood pressure readings can vary depending on location, vascular condition, or previous surgeries (e.g., mastectomy or AV fistula). It allows for trend comparison and ensures consistency in future assessments.
🔹When a blood pressure reading is abnormal, the nurse may take actions such as elevating the legs, administering antihypertensives, or holding medication. Documenting these interventions demonstrates clinical decision-making, supports continuity of care, and meets legal and ethical documentation standards.
🔹BP values can change significantly depending on whether the client is supine, sitting, or standing. For example, orthostatic hypotension is diagnosed based on changes with position. Proper documentation of position is essential for accurate interpretation and diagnosis.
🔹Noting how the client responded to a BP-related intervention helps determine effectiveness and safety of care. For instance, if repositioning improved a low BP, that outcome validates the intervention. This feedback loop supports clinical evaluation and nursing accountability.
Want to practice more questions like this?
This question is from RN Fundamentals Vital Assessment Quiz Final which contains 20 questions.
More Questions from This Exam
A nurse performing an assessment would correctly note that an absent pulse in one or more of the extremities indicates
Answer Choices:
A. Decreased plasma volume.
B. Problems with the heart's electrical conduction system.
C. Shock.
D. A blockage of blood flow.
While performing an admission history on a confused patient, a licensed practical nurse (LPN) assists the registered nurse (RN) by collecting secondary information about the patient. An example of secondary information would be that
Answer Choices:
A. The patient's spouse reports experiencing marital issues.
B. The patient reports a history of chest pain.
C. The patient complains of chronic constipation.
D. The patient verbalizes anxiety about hospitalization.
During the physical assessment, the nurse asks an elderly female patient if she experiences constipation. The nurse knows that
Answer Choices:
A. It is common for intestinal peristalsis to slow down as a person ages, causing problems with constipation.
B. Aging patients always have difficulty having a bowel movement while hospitalized
C. Elderly patients almost always abuse laxatives, which creates problems with constipation.
D. In elderly patients, the rectal sphincter has lost elasticity, which decreases the sensation of urgency.
A nurse is unable to palpate a client's dorsalis pedis pulse. The nurse will next attempt to palpate the
Answer Choices:
A. Carotid pulse
B. Brachial pulse
C. Posterior tibialis
D. Femoral pulse
A nurse is caring for a client who has an oral temperature of 39.50C (103.10F). Which of the following actions should the nurse take?
Answer Choices:
A. Remove excess clothing from the client.
B. Restrict the client's fluid intake.
C. Place a warming blanket over the client.
D. increase the temperature in the client's room
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Fundamentals of Nursing
- Answer Choices: 5
Was this question helpful?
0/5 average rating
(0 votes)