Which of the following is the correct procedure for measuring a patient's blood pressure using a manual sphygmomanometer?
Allow the patient to talk during the procedure to help them relax and maintain normal blood pressure levels.
Inflate the cuff quickly to 200 mmHg regardless of the patient's normal blood pressure to ensure accuracy.
Wrap the cuff over the patient's clothing to avoid discomfort and position the stethoscope over the radial artery.
Place the cuff on the patient's bare arm, ensuring it is level with the heart, and position the stethoscope over the brachial artery.
The Correct Answer is D
Rationale:
A. Allowing the patient to talk during the procedure is incorrect because talking can artificially elevate blood pressure readings. The patient should remain quiet and relaxed to obtain an accurate measurement.
B. Inflating the cuff quickly to 200 mmHg regardless of the patient’s normal blood pressure is incorrect because unnecessarily high inflation can cause discomfort and pain and may increase the risk of vascular injury. Blood pressure should be measured by inflating the cuff 30 mmHg above the patient’s estimated systolic pressure.
C. Wrapping the cuff over clothing is incorrect because clothing can interfere with accurate readings by preventing proper cuff inflation and transmission of pressure. Additionally, the stethoscope should be placed over the brachial artery, not the radial artery, when measuring blood pressure manually.
D. Placing the cuff on the patient’s bare arm, ensuring it is level with the heart, and positioning the stethoscope over the brachial artery is correct. Proper positioning ensures that the cuff compresses the artery evenly, the stethoscope accurately detects Korotkoff sounds, and the reading reflects true blood pressure. Accurate technique involves the patient seated or lying with the arm supported at heart level, cuff size appropriate to arm circumference, inflation above systolic pressure, and slow deflation while listening for the first and last Korotkoff sounds to determine systolic and diastolic pressures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Age-related skin changes typically include thinning, dryness, wrinkles, and decreased elasticity. They do not cause blue discoloration (cyanosis) of the lips and nail beds. Therefore, this finding is not considered a normal age-related change.
B. Blue discoloration of the lips and nail beds, known as cyanosis, indicates possible hypoxia, meaning the body’s tissues may not be receiving adequate oxygen. This is a clinical sign that requires prompt assessment and intervention to identify the underlying cause and prevent complications.
C. While individuals with darker skin tones may have variations in skin pigmentation, cyanosis is still detectable on the lips, tongue, nail beds, and mucous membranes. It is not considered a normal baseline finding in darker skin; a bluish tint in these areas should always prompt evaluation for hypoxia.
D. Exposure to heat typically causes vasodilation, which can result in redness, warmth, or flushing of the skin. It does not cause blue discoloration, so this finding is not consistent with a response to heat.
Correct Answer is A
Explanation
Rationale:
A. Reporting the finding to the provider for further evaluation is correct. The lesion’s characteristics—irregular shape, uneven borders, color variation, and size over 1 cm—are warning signs for malignant melanoma or other skin cancers. Prompt evaluation by a healthcare provider is necessary for early diagnosis and treatment, which can significantly improve outcomes.
B. Documenting the lesion as an expected finding is incorrect because these features are abnormal and potentially serious, not typical skin variations. Treating it as expected could delay critical care.
C. Instructing the client to apply moisturizing lotion is incorrect because moisturizers do not address abnormal pigmented lesions. This action does not prevent progression or provide diagnostic clarity.
D. Reassessing the lesion during the next routine assessment is incorrect because delaying evaluation could allow a malignant lesion to grow or metastasize. Immediate reporting is the priority to ensure timely medical assessment.
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