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 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.
Correct Answer is A
Explanation
Rationale:
A. A normal adult pupil size under typical lighting conditions is about 3 to 5 mm. Pupils constrict in bright light and dilate in dim light, but this range represents the expected baseline in average lighting. This option is correct.
B. A pupil size of 1 to 2 mm is considered constricted (miosis) and may be seen in conditions such as opioid use or certain neurological disorders. This is below the normal range, making this option incorrect.
C. A pupil size of 5 to 7 mm is larger than normal for standard lighting and may indicate dilation (mydriasis), which can occur in low light, stress, or certain drug effects. This is not typical under normal lighting, so it is incorrect.
D. A pupil size of 7 to 9 mm is significantly dilated and often associated with severe neurological conditions, drug effects, or very dark environments. This is not a normal finding in standard lighting conditions, making this option incorrect.
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