A false high blood pressure reading may be obtained if the nurse:
A. Deflates the cuff too slowly
B. Has the client's arm above the heart level
C. Holds the stethoscope too firmly over the antecubital fossa
D. Repeats the blood pressure assessments too quickly
A
A. Slowly release pressure bulb valve, and allow manometer needle to fall at rate of 2 to 3 mm Hg/sec. Note point on manometer when first clear sound is heard. The sound will slowly increase in intensity. Too rapid or slow a decline in mercury level can cause inaccurate readings. Loose-fitting cuff causes false high readings.
B. Placement of arm above the level of the heart causes false low reading
C. Proper stethoscope placement ensures optimal sound reception. Stethoscope improperly positioned causes muffled sounds that often result in false low systolic and false high diastolic readings
D. Continuous cuff inflation causes arterial occlusion, resulting in numbness and tingling of client's arm.
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