A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?
Select a cuff that covers 50% of the client’s upper arm.
Place the blood pressure cuff 5 cm (2 in) above the client’s antecubital space.
Elevate the client’s arm above the level of the heart.
Align the artery indicator on the blood pressure cuff with the client’s brachial artery.
The Correct Answer is D
When taking an electronic blood pressure measurement, it is important to properly position the cuff on the client’s arm. The artery indicator on the blood pressure cuff should be aligned with the client’s brachial artery1. It is also important to select a cuff that fits properly and to have the client sit comfortably with their back supported and feet flat on the ground2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A high white blood cell (WBC) count usually indicates an increase in the production of white blood cells to fight an infection
Correct Answer is C
Explanation
Supplemental oxygen is administered to increase the amount of oxygen in the body and improve tissue oxygenation. The goal of this intervention is to improve the client's condition and reduce symptoms of hypoxia.
Options a, b, and d are all indicative of ongoing hypoxia and are not desirable outcomes. An increase in heart rate and respiratory rate and restlessness can be a sign that the client is still struggling to breathe and not getting enough oxygen.
Option c, pink mucous membranes, is indicative of improved tissue oxygenation. The mucous membranes, such as those in the mouth and nose, should be a healthy pink color when oxygen levels are adequate. Therefore, the nurse should identify pink mucous membranes as an indication that the intervention was effective in improving the client's hypoxia.
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