The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)

dialysis shunt.

2-year-old hand amputation.

previous mastectomy.

patent IV line.

Answer and Explanation

Correct Answer : A,C

A.   A dialysis shunt requires careful monitoring to avoid damaging the shunt, and blood pressure cuffs should not be applied to the arm with a shunt.
B.   A hand amputation does not affect the use of the blood pressure cuff, but care should be taken with the affected area.
C.   A previous mastectomy increases the risk of lymphedema, and using a blood pressure cuff on the affected arm could exacerbate this.
D.   A patent IV line is not a contraindication for blood pressure measurement, but the nurse should take care not to interfere with the IV.

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Correct Answer is A

Explanation

A. Allowing the patient to sit on the side of the bed helps to prevent sudden drops in blood pressure and allows the body to adjust to the change in position, reducing the risk of fainting or dizziness.
B. Using a wheelchair for mobility may not address the root cause of orthostatic hypotension and may limit the patient's independence.
C. Keeping the patient in a high Fowler's position could worsen the symptoms of orthostatic hypotension.
D. Rising quickly could lead to a sudden drop in blood pressure and increase the risk of a fall or injury.

A. pump up the cuff until no sound is heard and then let the air out. B. stop midway and begin to inflate again. C. make sure the bell of the stethoscope is placed firmly over the artery. D. continue to listen until the cuff is deflated.

Correct Answer is D

Explanation

Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.

C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.

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The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)

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Naxlex Comprehensive Predictor Exams

Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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