The nurse prepares to assess a client's temperature.
Which should the nurse keep in mind that can falsely lower the body temperature? (Select all that apply.)

Choice A rationale:

Obtaining the blood pressure first thing in the morning is not the most critical factor in accurately measuring blood pressure. Blood pressure can vary throughout the day due to various factors, and it is essential to use the appropriate technique and equipment at any time of the day.

Choice B rationale:

Using the appropriate size cuff for the client is crucial in obtaining an accurate blood pressure reading. If the cuff is too small, it can lead to falsely elevated blood pressure readings, while a cuff that is too large can result in falsely lowered readings. This is because cuff size affects the pressure applied to the artery during measurement.

Choice C rationale:

Ensuring that the client is relaxed and comfortable prior to obtaining the blood pressure is important but not the most critical factor. Anxiety or discomfort can temporarily elevate blood pressure, so it's essential to create a calm and comfortable environment for the client. However, using the correct cuff size is still more critical for accurate measurements.

Choice D rationale:

Removing clothing from the arms before obtaining blood pressure is not the most important action. While it is generally recommended to expose the client's arm for proper cuff placement, it is secondary to using the appropriate cuff size. The cuff should be placed directly on the skin or over a thin layer of clothing, but this step should not take precedence over cuff size selection.

Choice A rationale:

Proper hand-washing technique involves washing hands for at least 20 seconds. This duration ensures thorough cleansing and removal of germs, dirt, and contaminants from the hands. Washing for a shorter time, such as 10 seconds (Choice B), may not effectively eliminate all harmful microorganisms, increasing the risk of infections and transmission of diseases.

Choice B rationale:

Washing hands for only 10 seconds is insufficient to achieve the necessary level of cleanliness. It is essential to follow recommended guidelines to prevent the spread of infections in healthcare settings and other environments where hygiene is crucial.

Choice C rationale:

Washing hands for 45 seconds (Choice C) is longer than the recommended duration and might not be practical, especially in busy healthcare settings. While thorough hand hygiene is essential, excessively long washing times could lead to reduced compliance among healthcare workers, potentially compromising patient safety.

Choice D rationale:

Proper hand-washing technique involves scrubbing hands for at least 20 seconds, making Choice D incorrect. Following the recommended guidelines is crucial to maintaining a safe and hygienic healthcare environment.