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. Blood pressure of 130/85 mmHg is slightly above normal, and a respiratory rate of 22 breaths/min is at the upper limit of normal, which may indicate mild tachypnea. Temperature of 100°F is slightly elevated. These values are not considered fully normal for a healthy adult at rest.
B. Heart rate of 55 bpm is slightly below normal, and respiratory rate of 10 breaths/min is at the lower limit, which may be bradycardic or hypoventilating depending on the context. Temperature of 97°F is slightly below average. While some healthy adults may have these values, they are borderline and not considered standard normal ranges.
C. Blood pressure 120/80 mmHg, heart rate 72 bpm, respiratory rate 16 breaths/min, and temperature 98.6°F all fall within the accepted normal range for a healthy adult at rest. This set accurately represents normal adult vital signs.
D. Blood pressure 140/90 mmHg is considered elevated (stage 2 hypertension), and heart rate 100 bpm is at the upper limit of normal. Temperature 99.5°F is slightly elevated. Overall, these values indicate borderline or mildly abnormal vital signs rather than fully normal values.
Correct Answer is C
Explanation
Rationale:
A. Palpating both carotid arteries at the same time is unsafe because it can significantly reduce blood flow to the brain, potentially causing dizziness, syncope (fainting), or even cerebral ischemia. The nurse should never occlude both carotid arteries simultaneously.
B. The thumb should not be used for palpation because it has its own strong pulse, which can be mistaken for the client’s pulse and lead to inaccurate assessment. The fingertips (index and middle fingers) are preferred because they are more sensitive and do not have a strong intrinsic pulse.
C. The correct technique is to gently palpate one carotid artery at a time using the fingertips. Gentle pressure allows the nurse to assess rate, rhythm, and strength of the pulse without compromising blood flow or stimulating the carotid sinus excessively. This is the safest and most accurate method.
D. Applying very firm pressure is dangerous, as it can stimulate the carotid sinus, leading to a vagal response (bradycardia, hypotension, or syncope). Excessive pressure can also temporarily obstruct blood flow to the brain. Therefore, only light to moderate pressure should be used.
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