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

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:

Airborne transmission typically involves smaller particles that can remain suspended in the air for longer periods. Sneezing, in this case, usually produces smaller droplets that can travel farther distances and potentially infect individuals beyond a few feet away.

Choice B rationale:

Direct contact transmission occurs when there is physical contact between an infected person and a susceptible individual. In this scenario, the infected drainage from the client's wound directly touches the nurse's cut, leading to infection. This type of transmission is characterized by the transfer of microorganisms through physical touch or contact with the skin.

Choice C rationale:

Droplet contact transmission involves larger respiratory droplets that are expelled when a person coughs, sneezes, or talks. These droplets typically do not travel far and can only infect people who are in close proximity. In this case, the scenario describes a client coughing on their hand and another person becoming infected by touching the contaminated door handle. This aligns with direct contact transmission rather than droplet contact transmission.

Choice D rationale:

Indirect contact transmission refers to the transfer of an infectious agent from a contaminated surface or object to a susceptible person. However, the scenario provided does not involve the nurse coming into contact with a contaminated surface but rather with the infected drainage directly. Therefore, this scenario is best categorized under direct contact transmission.