Exhibits
Lamont the procedure, but she also wants to explain some important concepts. What should she include? Select the 4 correct answers, (Case Study #1)
Choose a cuff that is the right size.
Support the extremity.
Have the patient cross their legs while taking blood pressure.
Ensure proper cuff application.
Ensure that the patient is sitting or lying.
Correct Answer : A,B,D,E
A. Choose a cuff that is the right size. Using the correct cuff size is essential for accurate blood pressure readings. A cuff that is too small can falsely elevate readings, while a cuff that is too large can falsely lower them.
B. Support the extremity. The arm should be supported at heart level to prevent unnecessary muscle strain, which could affect blood pressure readings. An unsupported arm may lead to an artificially higher reading.
C. Have the patient cross their legs while taking blood pressure. Crossing the legs can increase blood pressure by reducing venous return and increasing vascular resistance, leading to inaccurate measurements. The patient should keep their feet flat on the floor.
D. Ensure proper cuff application. The cuff should be placed snugly around the upper arm with the artery marker positioned correctly over the brachial artery. Improper placement can lead to inaccurate readings.
E. Ensure that the patient is sitting or lying. Blood pressure should be measured while the patient is in a stable position—either sitting with feet flat on the floor or lying down. Standing may result in postural changes that can alter blood pressure readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Brachial artery. The brachial pulse is commonly used in infants but is not the best choice for assessing circulation in an unconscious adult.
B. Carotid artery. The carotid artery is the preferred site for assessing a pulse in an unconscious adult because it is a central pulse with strong circulation, even in low-perfusion states.
C. Radial artery. The radial pulse is a peripheral pulse and may be difficult to palpate if the patient has poor circulation or cardiac arrest. The carotid pulse is more reliable in emergencies.
D. Apical artery. There is no apical artery; the apical pulse is auscultated over the heart with a stethoscope and is not used in emergency pulse checks.
Correct Answer is A
Explanation
A. Apical. The apical pulse, located at the apex of the heart, provides the most accurate measurement of heart rate, especially in patients with irregular rhythms. It is assessed by auscultation with a stethoscope over the fifth intercostal space at the midclavicular line.
B. Radial. The radial pulse is commonly used for routine pulse checks, but it may be less accurate in cases of irregular heart rhythms or weak peripheral circulation.
C. Brachial. The brachial pulse is typically used in infants and for blood pressure measurements, but it is not the most accurate method for assessing heart rate.
D. Popliteal. The popliteal pulse is located behind the knee and is used to assess circulation to the lower extremities, not for measuring heart rate accurately.
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