A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?
Select a cuff that covers 50% of the client’s upper arm.
Place the blood pressure cuff 5 cm (2 in) above the client’s antecubital space.
Elevate the client’s arm above the level of the heart.
Align the artery indicator on the blood pressure cuff with the client’s brachial artery.
The Correct Answer is D
When taking an electronic blood pressure measurement, it is important to properly position the cuff on the client’s arm. The artery indicator on the blood pressure cuff should be aligned with the client’s brachial artery1. It is also important to select a cuff that fits properly and to have the client sit comfortably with their back supported and feet flat on the ground2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
An oxygen saturation of 88% is below the normal range of 95-100%, indicating that the client may be experiencing hypoxia. Encouraging the client to take deep breaths can help increase their oxygen saturation level.
Correct Answer is A
Explanation
Fall prevention involves managing a patient’s underlying fall risk factors and optimizing the hospital’s physical design and environment1. Providing under-bed lighting at night can help reduce the risk of falls.
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