The patient is morbidly obese and the nurse uses a blood pressure (BP) cuff that is too narrow for the patient's arm. What problem will the nurse encounter because of the cuff used?
a. The Korotkoff sounds will not be heard.
b. Only a palpable BP can be obtained.
c. The stethoscope cannot be positioned correctly.
d. A false high BP reading will occur.
D
Using a cuff that is too narrow results in a false high BP measurement and makes care planning impossible. A properly sized cuff should be obtained as quickly as possible. Until it arrives, the nurse should continue to measure BP with the smaller cuff and observe the patient to ensure safety. Obesity potentially leads to diminished Korotkoff sounds. The assessment finding will warrant further investigation such as rechecking the blood pressure in several minutes. A palpable BP provides a systolic pressure only; the nurse obtains a palpable BP by inflating the cuff to occlude the artery and then palpating the brachial or radial pulse. The point at which the pulse returns is the systolic pressure. The nurse should have less difficulty positioning the stethoscope because the narrow cuff exposes more skin.
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