Difficulty: Medium
Average Score: 75%
Simulated
A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?
Correct answer
B
Rationale
Correct Answer: B - Places the client's arm above the level of the client's heart
Rationale: When measuring blood pressure, the client's arm should be at heart level to ensure accurate readings. Placing the arm above the heart level can give a falsely low reading. This is because gravity affects the pressure in the arm when it is positioned higher or lower than the heart. Therefore, instructing the partner to place the arm at or below heart level is essential for accurate blood pressure measurement.
Summary of Incorrect Choices:
A: Checking the instrument gauge is important to ensure accurate readings.
C: Wrapping the cuff snugly is necessary for an accurate measurement.
D: Centering the cuff bladder over the brachial artery is crucial for proper placement.
E, F, G: No other choices provided.
Rationale: When measuring blood pressure, the client's arm should be at heart level to ensure accurate readings. Placing the arm above the heart level can give a falsely low reading. This is because gravity affects the pressure in the arm when it is positioned higher or lower than the heart. Therefore, instructing the partner to place the arm at or below heart level is essential for accurate blood pressure measurement.
Summary of Incorrect Choices:
A: Checking the instrument gauge is important to ensure accurate readings.
C: Wrapping the cuff snugly is necessary for an accurate measurement.
D: Centering the cuff bladder over the brachial artery is crucial for proper placement.
E, F, G: No other choices provided.