The nurse needs to take a blood pressure on a very thin client, and the only cuff available is a standard size. Which type of blood pressure reading does the nurse expect?
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.
Correct Answer: 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. 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. When the bladder of the cuff is too narrow, the blood pressure reading will be falsely elevated. 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.
You might also like to view...
A nurse is caring for a patient who has just had a successful liver transplant. When facilitating the patient's treatment with cyclosporine, the nurse should anticipate that administration will
A) consist of daily intramuscular injections. B) begin with IV administration and then change to the oral route. C) involve daily IV administration via a central line. D) consist of topical administration to the abdominal region.
A parent is concerned that a 3-year-old child only wants to eat peanut butter and jelly at every meal. What should the nurse encourage the parent to do?
a. Allow the child to get up and move around while eating b. Insist the child eat whatever food is prepared for the meal c. Provide the child with peanut and butter and jelly only if that is what the child wants d. Continue to offer a variety of foods but allow the child to eat the peanut butter and jelly if it is preferred
The nurse is caring for a client who shares the same culture as other assigned clients. Which action should the nurse take when addressing this client's nutritional needs?
a. Assume that the client has no particular dietary issues b. Ask the client about any particular nutritional preferences c. Provide routine dietary actions unless the client asks otherwise d. Follow the same nutritional practices as the other clients from the same culture
The nurse has administered a scheduled dose of an antagonist to a client with mental illness. This drug will achieve a therapeutic effect by:
A) Preventing substances from activating cell function B) Reducing the client's number of synapses C) Accelerating the reuptake of neurotransmitters D) Stabilizing a receptor in an inactive state