The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?
a. Use the small cuff.
b. Use the large cuff.
c. Use either cuff using the palpation method.
d. Wait to take the blood pressure until a proper cuff can be located.
ANS: B
If blood pressure measurement is indicated and the appropriate size cuff is not available, the next larger size is used. The nurse recognizes that this may be a falsely low blood pressure. Using the small cuff will give an incorrectly high reading. The palpation method will not improve the inaccuracy inherent in the cuff.
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