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 D
Explanation
Choice A reason: The CRIES pain scale is not suitable for a 10-year-old as this scale is designed for neonates, typically those who are 0 to 6 months old.
Choice B reason: A 3-year-old toddler would be better assessed with a pain scale that allows for their level of understanding and communication, such as the Faces Pain Scale-Revised.
Choice C reason: A 4-year-old preschooler can typically communicate their pain verbally or by using a faces pain scale, making the CRIES scale less appropriate.
Choice D reason: The CRIES pain scale is specifically designed for neonates and is appropriate for assessing pain in a 4-day-old infant who cannot verbally communicate their pain.
Correct Answer is D
Explanation
Choice A reason: Inspection should be performed first to observe for any visible abnormalities, distention, or movements that could indicate underlying conditions.
Choice B reason: Percussion is used after auscultation to assess the presence of fluid, gas, and to estimate the size of the organs within the abdomen.
Choice C reason: Palpation is typically performed last because it can alter the natural state of the abdomen, potentially causing discomfort and affecting the bowel sounds that are assessed during auscultation.
Choice D reason: Auscultation should be performed before palpation and percussion to avoid altering bowel sounds. It allows the nurse to listen to the natural state of bowel motility and vascular sounds without interference.
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