The nurse is discussing the proper technique for obtaining an accurate

The nurse is discussing the proper technique for obtaining an accurate blood pressure reading with assistive nursing personnel.

Which of the following statements reflect techniques that will minimize the risk of a false high systolic reading? (Select all that apply.)
1. “Slowly deflate the pressure from the cuff.”
2. “Wrap the cuff snuggly around the client’s arm.”
3. “Always support the client’s arm at the level of the heart.”
4. “Be sure that the cuff is wide enough for the client’s arm.”
5. “Allow the arm to rest before repeating the blood pressure.”
6. “Make sure your stethoscope is fitted in your ears appropriately.”

ANSWER

ANS: 2, 3, 4, 5
Using a bladder or cuff that is too narrow or too short, wrapping the cuff too loosely or uneven-ly, resting the arm below heart level, and repeating assessments too quickly all contribute to a falsely high systolic reading. The rapid deflation of the cuff and an ill-fitted stethoscope will likely result in a falsely low systolic reading.