Questions: The nurse enters the room while a student nurse is taking a manual blood pressure on a client sitting in the chair. For which of the following observations should the nurse reinforce teaching with the student nurse? (Select all that apply.) The client is talking on the telephone and laughing. The client is crossing his legs. The client is drinking a cup of black tea. The air is released rapidly while auscultating for Korotkoff sounds. The cuff is positioned 2 cm above the antecubital fossa.

The nurse enters the room while a student nurse is taking a manual blood pressure on a client sitting in the chair. For which of the following observations should the nurse reinforce teaching with the student nurse? (Select all that apply.)
The client is talking on the telephone and laughing.
The client is crossing his legs.
The client is drinking a cup of black tea.
The air is released rapidly while auscultating for Korotkoff sounds.
The cuff is positioned 2 cm above the antecubital fossa.
Transcript text: The nurse enters the room while a student nurse is taking a manual blood pressure on a client sitting in the chair. For which of the following observations should the nurse reinforce teaching with the student nurse? (Select all that apply.) The client is talking on the telephone and laughing. The client is crossing his legs. The client is drinking a cup of black tea. The air is released rapidly while auscultating for Korotkoff sounds. The cuff is positioned 2 cm above the antecubital fossa.
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Solution

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The observations for which the nurse should reinforce teaching with the student nurse are:

  1. The client is talking on the telephone and laughing.

    • Explanation: When taking a manual blood pressure, the client should be at rest and not talking, as talking can affect the accuracy of the blood pressure reading. It can lead to an artificially high reading.
  2. The client is crossing his legs.

    • Explanation: Crossing legs can also affect blood pressure readings, potentially causing an increase in systolic pressure. The client should have both feet flat on the floor for an accurate measurement.
  3. The air is released rapidly while auscultating for Korotkoff sounds.

    • Explanation: Releasing the air too quickly can result in missing the Korotkoff sounds, leading to an inaccurate blood pressure reading. The air should be released slowly and steadily to ensure accurate detection of these sounds.

The other observations do not necessarily require reinforcement of teaching:

  • The client is drinking a cup of black tea.

    • Explanation: While caffeine can affect blood pressure, the immediate act of drinking tea during the measurement is not as critical as the other factors listed. However, it is generally advised to avoid caffeine 30 minutes before a blood pressure reading.
  • The cuff is positioned 2 cm above the antecubital fossa.

    • Explanation: This is generally an appropriate position for the cuff, as it should be placed above the antecubital fossa to ensure accurate measurement.

In summary, the nurse should reinforce teaching regarding the client talking and laughing, crossing legs, and the rapid release of air during the blood pressure measurement.

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