A nurse notes a client's pulse is a 2+ and understands this means what about the pulse?

Choice A rationale:

Obtaining the blood pressure first thing in the morning is not the most critical factor in accurately measuring blood pressure. Blood pressure can vary throughout the day due to various factors, and it is essential to use the appropriate technique and equipment at any time of the day.

Choice B rationale:

Using the appropriate size cuff for the client is crucial in obtaining an accurate blood pressure reading. If the cuff is too small, it can lead to falsely elevated blood pressure readings, while a cuff that is too large can result in falsely lowered readings. This is because cuff size affects the pressure applied to the artery during measurement.

Choice C rationale:

Ensuring that the client is relaxed and comfortable prior to obtaining the blood pressure is important but not the most critical factor. Anxiety or discomfort can temporarily elevate blood pressure, so it's essential to create a calm and comfortable environment for the client. However, using the correct cuff size is still more critical for accurate measurements.

Choice D rationale:

Removing clothing from the arms before obtaining blood pressure is not the most important action. While it is generally recommended to expose the client's arm for proper cuff placement, it is secondary to using the appropriate cuff size. The cuff should be placed directly on the skin or over a thin layer of clothing, but this step should not take precedence over cuff size selection.

The correct answer is Choice C.

Choice A rationale: Using a fire extinguisher is part of containment, but it follows evacuation. Attempting to extinguish before removing clients violates RACE protocol and risks patient injury from smoke or electrical fire.

Choice B rationale: Activating the fire alarm initiates emergency response but comes after client rescue. Per RACE (Rescue, Alarm, Contain, Extinguish), client safety is prioritized before system-wide alerts.

Choice C rationale: Moving clients to safety is the first step in fire response. It aligns with the “Rescue” phase of RACE, ensuring immediate protection from smoke inhalation, electrical hazards, and fire spread.

Choice D rationale: Confine by closing doors and windows is part of containment, which follows rescue and alarm activation. It helps limit fire spread but is not the initial priority in patient-centered emergencies.