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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Clean gloves are necessary when touching or being in close proximity to any wound, especially one that is infected with MRSA. MRSA is a highly contagious bacterium that can spread through direct contact with the infected area or through indirect contact with contaminated objects. Wearing clean gloves helps prevent the transmission of MRSA to the nurse and to other patients.

Choice B reason: Protective eyewear is not typically required for checking a patient's pulse. However, if there is a risk of splashing or spraying of bodily fluids, protective eyewear becomes necessary to protect the mucous membranes of the eyes from exposure to infectious materials.

Choice C reason: Sterile gloves are used during procedures that require an aseptic technique, such as the changing of a sterile dressing or during invasive procedures. Checking a patient's pulse does not require sterile gloves, as it is not an aseptic procedure.

Choice D reason: A surgical mask should be worn if there is a risk of droplet transmission or if the nurse will be in close contact with the patient's wound. MRSA can be present in nasal secretions and can be spread by droplets, so wearing a mask can provide an additional layer of protection against the transmission of MRSA.

A. "I will not wear artificial nails when providing client care." B. "I should wash my hands when they are visibly dirty." C. "As long as I change my gloves between clients, it is not necessary to wash my hands." D. "It is acceptable to use alcohol-based hand products after most contacts with clients." E. The correct answer is c. "As long as I change my gloves between clients, it is not necessary to wash my hands."

Correct Answer is C

Explanation

Choice A reason: Not wearing artificial nails during client care is a recommended practice to prevent the spread of infection, as artificial nails can harbor bacteria.

Choice B reason: Washing hands when they are visibly dirty is correct, but hand hygiene should also be performed at other times, such as before and after patient contact, regardless of the appearance of cleanliness.

Choice C reason: Changing gloves is not a substitute for hand washing. Hand hygiene is necessary before donning gloves and after removing them to prevent the transmission of pathogens.

Choice D reason: Using alcohol-based hand products is a standard practice in healthcare settings and is effective in killing most bacteria and viruses when the hands are not visibly soiled.

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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?

Choice A: Wrapping the cuff too loosely around the client’s arm

Choice B: Measuring blood pressure right after the client’s mealtime

Choice C: Positioning the client’s arm above heart level

Choice D: Deflating the cuff too slowly

Nursing Test Bank

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