Using a small adult-sized cuff, the nurse takes a client's blood pressure with a larger upper arm. What results will the nurse likely obtain:

Accurate

Indistinct

Falsely high

Falsely low

Answer and Explanation

The Correct Answer is C

A. Accurate: Correct accuracy requires an appropriately sized cuff; using an improperly small cuff is unlikely to produce an accurate reading.

B. Indistinct: While the Korotkoff sounds might still be audible, the primary effect of a cuff that’s too small is a systematic error in the reading rather than mere indistinctness.

C. Falsely high: A cuff that is too small (or too narrow) for the arm requires higher inflation pressure to occlude the artery, producing a falsely elevated blood pressure reading.

D. Falsely low: A cuff that is too large for a small arm tends to give falsely low readings; the opposite mismatch (small cuff on large arm) tends to overestimate.

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Correct Answer is B

Explanation

A. Vesicular breath sounds: Vesicular sounds are normal, soft, low-pitched breath sounds heard over peripheral lung fields and are not described as coarse or pain-associated.

B. Pleural friction rub: A pleural friction rub is a coarse, grating sound synchronous with respiration and is often associated with pleuritic chest pain, matching this description.

C. Atelectasis: Atelectasis often causes diminished or absent breath sounds and possibly fine crackles during deep breaths, not a coarse sound in rhythm with breathing.

D. Fine rales: Fine rales (crackles) are high-pitched, intermittent popping sounds, usually at end-inspiration, and are not the coarse, pleuritic-synchronous sound described.

A. Apply heat to bony prominences B. Reposition the client every 2 hours C. Massage reddened areas D. Increase fluid restriction

Correct Answer is B

Explanation

A. Apply heat to bony prominences: Applying heat to pressure points can increase local tissue metabolic demand and may worsen ischemia; heat is not a preventive measure for pressure ulcers.

B. Reposition the client every 2 hours: Regular repositioning relieves prolonged pressure over bony prominences, redistributes weight, and is a primary preventive intervention to reduce pressure ulcer risk.

C. Massage reddened areas: Massaging areas of redness can further damage capillaries and underlying tissue and is generally discouraged; instead, avoid pressure and inspect frequently.

D. Increase fluid restriction: Adequate hydration supports skin integrity; restricting fluids can impair tissue perfusion and healing and would not prevent ulcers.

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Using a small adult-sized cuff, the nurse takes a client's blood pressure with a larger upper arm. What results will the nurse likely obtain:

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