When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?
Wrapping the cuff too loosely around the client's arm
Measuring blood pressure right after the client's mealtime
Positioning the client's arm above heart level
Deflating the cuff too slowly
The Correct Answer is C
The correct answer is: c. Positioning the client’s arm above heart level.
Choice A: Wrapping the cuff too loosely around the client’s arm
Wrapping the cuff too loosely can lead to an inaccurately high blood pressure reading, not a low one. A loose cuff does not compress the artery properly, causing the device to overestimate the pressure needed to occlude the artery.
Choice B: Measuring blood pressure right after the client’s mealtime
Measuring blood pressure right after a meal can cause a slight increase in blood pressure due to the body’s metabolic response to digestion. This is not a common cause of a low blood pressure reading.
Choice C: Positioning the client’s arm above heart level
Positioning the client’s arm above heart level can lead to an inaccurately low blood pressure reading. When the arm is elevated, the hydrostatic pressure decreases, resulting in a lower reading. This is a well-known source of error in blood pressure measurement.
Choice D: Deflating the cuff too slowly
Deflating the cuff too slowly can cause venous congestion, which may lead to an inaccurately high reading rather than a low one. The standard deflation rate is 2-3 mm Hg per second to ensure accurate measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Airborne precautions are used for diseases that are spread through the air over long distances, such as tuberculosis, measles, or chickenpox. VRE is not typically spread through the air.
Choice B reason: Droplet precautions are used for diseases that are spread through large droplets in the air, such as influenza or pertussis. VRE is not spread through droplets but through contact with contaminated surfaces or equipment.
Choice C reason: A protective environment is designed to protect immunocompromised patients from infection and is not typically used for patients with VRE. This type of precaution includes the use of HEPA filters, laminar air flow, and other strategies to maintain a sterile environment.
Choice D reason: Contact precautions are the appropriate measures for a patient with a VRE infection. VRE can be spread from one person to another through contact with contaminated surfaces or equipment or through person-to-person spread, often via contaminated hands. It is not spread through the air by coughing or sneezing. Therefore, contact precautions, including the use of gloves and gowns, are necessary when caring for patients with VRE to prevent the spread of the bacteria.
Correct Answer is A
Explanation
Choice A reason: Urinary catheterization is a well-known risk factor for HAIs, particularly catheter-associated urinary tract infections (CAUTIs). The use of indwelling urinary catheters can introduce bacteria into the urinary tract and is associated with a significant proportion of HAIs.
Choice B reason: While malnutrition can affect the immune system and increase the risk of infections, it is not a direct cause of HAIs. Good nutritional status is important for wound healing and infection prevention, but it does not cause HAIs by itself.
Choice C reason: Having multiple caregivers can increase the risk of transmitting infections, especially if hand hygiene and other infection control practices are not consistently followed. However, it is not considered a direct cause of HAIs like urinary catheterization is.
Choice D reason: Chlorhexidine washes are actually used as a preventive measure against HAIs, particularly in reducing the risk of surgical site infections. They are not a cause of HAIs but rather part of the solution to prevent them.
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