A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?

Use a cuff of the appropriate size for the client.

Assist the client to the bathroom to void.

Apply the cuff loosely around the client's arm.

Obtain the reading in the early morning.

Answer and Explanation

The Correct Answer is A

A. Use a cuff of the appropriate size for the client:
Using a cuff that is too small or too large can cause inaccurate readings. Proper sizing is crucial.

B. Assist the client to the bathroom to void:
While a full bladder can slightly affect BP, this is not the most essential step to ensure an accurate reading.

C. Apply the cuff loosely around the client’s arm:
A loose cuff will cause an inaccurate (falsely high) reading.

D. Obtain the reading in the early morning:
While BP naturally varies, the time of day is not critical to accurate technique unless part of a specific assessment schedule.

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Correct Answer is B

Explanation

A. Elevate the client’s arm above the level of the heart:
This may falsely lower the reading. The arm should be at heart level.

B. Align the artery indicator on the BP cuff with the client’s brachial artery:
Correct alignment ensures accurate readings. Most cuffs have an arrow or line that must align with the brachial artery.

C. Place the BP cuff 5 cm (2 in) above the client’s antecubital space:
The cuff should be placed about 2.5 cm (1 inch) above the antecubital space-not 5 cm.

D. Select a cuff that covers 50% of the client’s upper arm:
The correct cuff should cover at least 80% of the arm’s circumference, not 50%, for accurate readings.

A. Cover the wound with a sterile normal saline soaked dressing. B. Apply an abdominal binder to the wound area. C. Assure the client that this is an expected occurrence after surgery. D. Turn the client onto her side.

Correct Answer is A

Explanation

A. Cover the wound with a sterile normal saline soaked dressing:
This keeps the exposed organs moist and reduces infection risk until surgical intervention.

B. Apply an abdominal binder to the wound area:
This can increase pressure and cause further damage to exposed organs.

C. Assure the client that this is an expected occurrence after surgery:
Evisceration is a surgical emergency, not expected.

D. Turn the client onto her side:
The client should be placed in a low Fowler’s position with knees bent to reduce abdominal strain-not on the side.

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A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?

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Naxlex Comprehensive Predictor Exams

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