The nurse needs to take a blood pressure on a very thin client, and the only cuff available is a standard size. The nurse would anticipate which of the following readings?

Question

1. An accurate reading
2. A falsely elevated reading
3. The reading will depend on the overall health of the client
4. A false low reading

Answer 1

4
Rationale 1: In a very thin client, a small (or even pediatric) blood pressure cuff should be used to obtain an accurate reading. Using a standard cuff on this client will yield a falsely low result.
Rationale 2: When the bladder of the cuff is too narrow, the blood pressure reading will be falsely elevated.
Rationale 3: While the reading will depend on the overall health of the client, it is important to obtain an accurate reading by using the proper equipment.
Rationale 4: In this situation, the bladder of the cuff is too wide, resulting in the blood pressure reading being falsely low. To obtain accurate blood pressure readings, it is imperative that the nurse select the proper cuff. The bladder of the blood pressure cuff must be an appropriate fit in both length and width for the client's arm. The length of the bladder should equal 80% of the circumference of the limb. The width of the bladder should equal 40% of the circumference of the limb.