The nurse is discussing the correct technique for taking a blood ...

[Yolanda]

The nurse is discussing the correct technique for taking a blood pressure with clients and their caregivers.
 
  Which of the following nursing statements would appropriately identify the most likely causes for experiencing difficulty actually hearing the blood pressure? (Select all that apply.)
  1. The cuff cannot be too small or too big.
  2. Don't release the air out of the cuff to quickly.
  3. Keep the arm you are using at the level of the heart.
  4. If you are having difficulty, try taking it in the other arm.
  5. The stethoscope needs to be placed directly over a pulse point.
  6. Remember to pump up the cuff until you can no longer feel the pulse.

Question 2

The position that maximizes the nurse's ability to assess the client's body for symmetry is:
 
  1. Sitting
  2. Supine
  3. Prone
  4. Dorsal recumbent

[pratush dev]

Answer to Question 1

ANS: 1, 2, 5, 6
Instruct the client or primary caregiver that if it is difficult to hear the pressure, the cuff is proba-bly too loose, not big enough, or too narrow; the stethoscope is not over an arterial pulse; the cuff was deflated too quickly or too slowly; or the cuff was not inflated enough for systolic readings. The remaining options do not directly affect the actual hearing of the blood pressure.

Answer to Question 2

ANS: 1
Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts. The supine position maximizes the nurse's ability to assess pulse sites. The prone position is used only to assess extension of the hip joint.
The dorsal recumbent position is used for abdominal assessment because it promotes relaxation of abdominal muscles.