The nurse selects a blood pressure cuff that is too small for the patient's arm. Which of the following outcomes is most likely?
Accurate blood pressure reading with possible discomfort
The reading will be falsely low
Inability to obtain any blood pressure reading
Falsely elevated blood pressure reading
The Correct Answer is D
Rationale:
A. This is incorrect because accuracy depends on using a correctly sized cuff. While a cuff that is too small may cause discomfort due to tightness, it will not provide a true measurement of the patient’s blood pressure. Discomfort alone does not ensure an accurate reading.
B. A cuff that is too large for the patient can cause falsely low readings because the cuff more easily compresses the artery. However, when the cuff is too small, the opposite occurs: the nurse must inflate the cuff to a higher pressure to occlude the artery, resulting in a falsely elevated reading.
C. Generally, a small cuff can still provide a reading. The problem is not that a measurement cannot be taken, but that the reading is inaccurate and consistently higher than the true blood pressure.
D. Using a cuff that is too small for the patient’s arm circumference increases the pressure needed to occlude the artery, leading to an overestimation of both systolic and diastolic blood pressures. This is a common error in clinical practice, particularly in patients with larger arms. Using the proper cuff size — where the bladder width is approximately 40% of the arm circumference and the length covers 80–100% of the arm — ensures accurate blood pressure readings and reduces the risk of misdiagnosis or inappropriate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. This is a significant finding that may indicate a neurologic deficit such as stroke or spinal cord injury. While urgent, it is not immediately life-threatening unless associated with respiratory compromise. Nursing priority is determined by airway, breathing, circulation (ABCs) first.
B. Guarding suggests pain, possibly from abdominal pathology such as peritonitis, appendicitis, or internal bleeding. This requires prompt assessment, but unless it is causing airway or breathing compromise, it is secondary in priority.
C. This indicates respiratory distress, which is a potentially life-threatening condition. Shortness of breath compromises oxygenation, making it the highest priority according to the ABCs framework. The nurse should immediately assess airway, oxygen saturation, respiratory effort, and be prepared to provide supplemental oxygen or other interventions.
D. This finding indicates a stable and non-urgent condition. There is no immediate risk to airway, breathing, or circulation.
Correct Answer is C
Explanation
Rationale:
A. Multiple open lesions on the lower legs are abnormal and may indicate infection, trauma, vascular compromise, or chronic conditions such as venous stasis ulcers. This finding requires further assessment and intervention, so it is not an expected skin finding.
B. Cyanosis around the lips indicates hypoxia or decreased oxygenation and is an abnormal finding. This requires immediate evaluation of the client’s respiratory and cardiovascular status. Cyanosis is never considered normal in adults.
C. Intact skin that is evenly pigmented is considered an expected and healthy finding in adults. It indicates that the skin is functioning properly as a protective barrier, has adequate perfusion, and shows no signs of injury, infection, or circulatory compromise.
D. Tented skin turgor indicates dehydration or loss of skin elasticity and is abnormal in adults. Normal skin turgor should return to its original position quickly when pinched. Persistent tenting reflects compromised fluid status or connective tissue changes.
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