Question

a nurse is preparing to measure a clients blood pressure. which of the following actions should the nurse take? use a cuff with a bladder that encircles 60% of the clients upper arm. position the clients arm at the level of the clients heart. wrap the cuff loosely around the clients arm. ensure the lower edge of the cuff is 1.3 cm (0.5 in) above the antecubital space.

Explanation:

To determine the correct action for measuring blood pressure:

• For the cuff bladder, it should encircle 80% (not 60%) of the upper arm, so the first option is incorrect.
• Positioning the client’s arm at heart level is a correct practice to ensure accurate blood pressure measurement, as hydrostatic pressure is minimized.
• The cuff should be wrapped snugly (not loosely) around the arm, so the third option is incorrect.
• The lower edge of the cuff should be 2.5 cm (1 in) above the antecubital space (not 1.3 cm/0.5 in), so the fourth option is incorrect.

Answer:

B. Position the client's arm at the level of the client's heart.