When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?
Wrapping the cuff too loosely around the client's arm
Measuring blood pressure right after the client's mealtime
Positioning the client's arm above heart level
Deflating the cuff too slowly
The Correct Answer is C
The correct answer is: c. Positioning the client’s arm above heart level.
Choice A: Wrapping the cuff too loosely around the client’s arm
Wrapping the cuff too loosely can lead to an inaccurately high blood pressure reading, not a low one. A loose cuff does not compress the artery properly, causing the device to overestimate the pressure needed to occlude the artery.
Choice B: Measuring blood pressure right after the client’s mealtime
Measuring blood pressure right after a meal can cause a slight increase in blood pressure due to the body’s metabolic response to digestion. This is not a common cause of a low blood pressure reading.
Choice C: Positioning the client’s arm above heart level
Positioning the client’s arm above heart level can lead to an inaccurately low blood pressure reading. When the arm is elevated, the hydrostatic pressure decreases, resulting in a lower reading. This is a well-known source of error in blood pressure measurement.
Choice D: Deflating the cuff too slowly
Deflating the cuff too slowly can cause venous congestion, which may lead to an inaccurately high reading rather than a low one. The standard deflation rate is 2-3 mm Hg per second to ensure accurate measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Avoiding large amounts of fluids before bedtime can help prevent disruptions in sleep due to the need to urinate during the night.
Choice B reason: Consuming alcohol, even in the form of a glass of wine, just before bedtime can interfere with the sleep cycle and lead to disrupted sleep.
Choice C reason: Engaging in brisk exercise before bedtime can be stimulating and may make it more difficult to fall asleep.
Choice D reason: Performing muscle relaxation techniques in the afternoon can help reduce overall tension but doing them closer to bedtime would be more beneficial for promoting sleep.
Correct Answer is A
Explanation
Choice A reason: This documentation is correct as it includes the pulse rate and the client's position when the measurement was taken, which can affect the reading.
Choice B reason: The temperature is documented with the correct unit of measurement, but it does not specify the method of measurement (oral, axillary, tympanic, etc.), which is important for accurate interpretation.
Choice C reason: Respirations should be observed, not auscultated, and the documentation should include the client's position. The term 'even' is unnecessary and could be confusing.
Choice D reason: The blood pressure reading is correctly documented with both systolic and diastolic values. However, it should also include the client's position and the arm in which the measurement was taken for clarity.
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.