To accurately take a client's blood pressure, which action by the nurse is most important?

Obtain the blood pressure first thing in the morning.

Use the appropriate size cuff for the client.

Make sure the client is relaxed and comfortable prior to obtaining the blood pressure.

Remove the clothing from arms before obtaining the blood pressure.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is C

Explanation

Choice A rationale:

This option is incorrect. Counting a regular pulse for 30 seconds and doubling the number is an appropriate method for assessing heart rate, not peripheral pulses. When assessing peripheral pulses, it is important to count the pulses directly for a full minute to accurately determine the pulse rate. This ensures that any irregularities or variations in the pulse rate are captured.

Choice B rationale:

This option is incorrect. Palpating the femoral artery in the groin is a standard method for assessing peripheral pulses. It is not a safety issue when performed correctly. However, the question asks about a safety issue related to assessing peripheral pulses.

Choice C rationale:

Palpating both carotid pulses at the same time is a safety issue when assessing peripheral pulses. Simultaneously palpating both carotid pulses can lead to excessive pressure on the carotid sinuses, which are baroreceptors located in the carotid arteries. Stimulation of these baroreceptors can result in a reflex decrease in heart rate and blood pressure, leading to a condition known as carotid sinus hypersensitivity. This can cause dizziness, fainting, or, in extreme cases, cardiac arrest. Therefore, it is essential to avoid palpating both carotid pulses simultaneously to prevent adverse reactions in clients, especially those with cardiovascular issues.

Choice D rationale:

Palpating the radial artery on the thumb side of the wrist is a standard method for assessing peripheral pulses. It is a safe and commonly used technique for evaluating radial pulse rate, rhythm, and amplitude. .

A. The anterior surface of the drape. B. The outer 1-inch border of the drape. C. The top inner corners of the drape. D. The posterior aspect of the drape.

Correct Answer is A

Explanation

Choice A rationale:

Standard precautions, as established by the Center for Disease Control (CDC), are to be used for any client, regardless of whether an infection has been identified. This means that healthcare providers, including nurses, must apply standard precautions in the care of all patients to prevent the spread of infections. The rationale behind this choice is based on the fundamental principle of infection control: it is not always possible to identify patients who may be carrying harmful pathogens. Some patients may not show visible signs of infection or may be in the incubation period of a disease, during which they are contagious but not symptomatic. Therefore, applying standard precautions universally helps to create a safe healthcare environment for both patients and healthcare providers. Standard precautions include practices such as hand hygiene, the use of personal protective equipment (PPE) like gloves and masks, safe injection practices, and respiratory hygiene.

Choice B rationale:

This choice incorrectly specifies the mode of transmission for using standard precautions. Standard precautions are not limited to cases where the infection is transmitted on air currents. Airborne precautions are used for diseases that spread via small droplets in the air, such as tuberculosis and measles. Standard precautions, on the other hand, cover a broader range of infections and are applied to all patients.

Choice C rationale:

This choice incorrectly narrows down the usage of standard precautions to cases where the infection spreads via moist droplets. While it is true that standard precautions include measures to prevent the transmission of infections through respiratory droplets, they are not limited to this mode of transmission. Standard precautions encompass various modes of transmission, including contact with blood and other body fluids, as well as contact with contaminated surfaces or items.

Choice D rationale:

This choice wrongly states that standard precautions are only used when there is an infection spread by indirect contact with an organism. Standard precautions include both direct and indirect contact with patients and their environment. It is not limited to specific types of infections or modes of transmission.

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