A patient is obese. At the bedside is a standard-size blood pressure cuff. The nurse realizes that the use of this cuff will provide which of the following?
A falsely high reading if the cuff is too small.
A falsely low reading if the cuff is wrapped too loosely around the arm.
Accurate readings as long as it is 20% of the circumference of the midpoint of the limb.
Indistinct readings if the bladder encircles 80% of the adult's arm
The Correct Answer is A
A. A falsely high reading if the cuff is too small:
Using a cuff that is too narrow for the arm circumference can compress the artery more, resulting in a false high BP.
B. A falsely low reading if the cuff is wrapped too loosely around the arm:
This is true if a cuff is loose, but the question focuses on using a standard-size cuff, not an improperly applied one.
C. Accurate readings as long as it is 20% of the circumference of the midpoint of the limb:
The correct cuff width should be 40% of the limb’s circumference, and the bladder length should cover 80% of the arm.
D. Indistinct readings if the bladder encircles 80% of the adult's arm:
A bladder covering 80% of the arm is ideal and yields accurate readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is D
Explanation
A. Decreased serum calcium:
Low calcium affects bones and muscle contraction but is not directly related to pressure injury development.
B. Increased muscle mass:
Increased muscle mass helps protect against pressure injury by providing padding and blood flow.
C. Decreased circulation:
Poor circulation leads to inadequate oxygen and nutrient delivery to tissues, increasing the risk of pressure injury, especially in immobile clients.
D. Increased collagen:
Collagen is essential for skin integrity and wound healing. Increased collagen would protect, not harm, tissue.
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.