A healthy adult patient tells the nurse that he obtained his blood pressure in “one of those quick machines in the mall” and was alarmed that it was 152/7B. He immediately repeated the measurement, and the value was 158/80. His normal BP value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/72? Select all that apply
Cuff too small on the device
Arm positioned above heart level
Slow inflation of the cuff by the machine
Patient did not remove his long-sleeved shirt
Insufficient time between measurements
Correct Answer : A,D,E
Blood pressure (BP) measurement is a foundational clinical assessment, but its accuracy is highly influenced by technique, cuff size, body position, and external factors.
Rationale for correct answers:
A. Cuff too small on the device: A cuff that is too small for the client’s arm can result in falsely elevated systolic pressure.
D. Patient did not remove his long-sleeved shirt: Taking BP over clothing can interfere with cuff compression and cause falsely high readings, especially thicker or tight sleeves.
E. Insufficient time between measurements: Taking repeat BP readings too soon (e.g., within 1–2 minutes) doesn’t allow time for vascular recovery and can lead to falsely high results.
Rationale for incorrect answers:
B. Arm positioned above heart level: If the arm is above heart level, BP readings tend to be falsely low, not high. To avoid error, the arm should be at heart level.
C. Slow inflation of the cuff by the machine: Slow deflation, not inflation, affects BP accuracy.
Take-home points:
- Improper cuff size, measuring over clothing, and not waiting long enough between readings can all cause falsely elevated BP.
- BP measurement should be performed with the arm at heart level, cuff directly on skin, and with the correct-sized cuff to ensure accuracy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Postoperative patients, especially those with heart failure, are at increased risk for orthostatic hypotension due to bedrest, anesthetic effects, and volume shifts. Orthostatic intolerance may manifest as dizziness, nausea, or fainting when the client is moved from lying to sitting or standing.
Rationale for correct answers:
A. Lower the head of the bed and return the patient to the supine position: This is the first and most important safety step to prevent fainting or falls. Returning to a supine position helps restore cerebral perfusion, relieving dizziness.
B. Obtain vital signs: Vital signs (especially blood pressure and heart rate) should be obtained to assess for orthostatic hypotension or other hemodynamic instability.
D. Allow the patient to rest for 20 to 30 minutes: After returning to a safe position, resting allows stabilization of blood pressure and heart rate. Many patients tolerate activity better after a brief rest period.
E. Raise the head of the bed again and obtain blood pressure readings: Gradually raising the head of the bed and monitoring orthostatic BPs is part of safely assessing tolerance to positional changes.
Rationale for incorrect answer:
C. Encourage the patient to try to sit on the side of the bed and then stand: Encouraging further movement while the patient is symptomatic is unsafe. Doing so may worsen symptoms and risk falls or cardiovascular collapse.
Take-home points:
- Immediate safety actions (return to supine, assess vitals) are essential when a patient becomes dizzy with movement.
- Orthostatic BP monitoring and gradual progression to activity can help prevent falls and guide safe ambulation.
Correct Answer is A
Explanation
Monitoring and interpreting body temperature is a fundamental nursing task used to assess homeostasis, detect infection, and guide treatment decisions. The normal oral temperature range for adults is typically between 3F.5°C to 37.5°C (97.7°F to 99.5°F).
Rationale for correct answer:
A. Fever (also called pyrexia) is defined as a body temperature above the normal range, typically greater than 38°C (100.4°F) when measured orally.
Rationale for incorrect answers:
B. Hypothermia refers to a core body temperature below 35°C (95°F).
C. Hypertension refers to elevated blood pressure, not body temperature.
D. Afebrile means without fever, or having a normal body temperature.
Take-home points:
- A temperature above 38°C (100.4°F) is classified as a fever and should be documented accordingly.
- Use accurate terminology for vital signs to ensure clear communication and proper follow-up care.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.