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Fundamentals: Skills Blood Pressure
(BP) Questions and Answers | Latest Version | 2025/2026 | Correct & Verified
A nurse is preparing to check a client’s blood pressure. What position should the client’s arm be in during the reading?✔✔At heart level with the palm facing upward
A nurse inflates the BP cuff to 200 mm Hg but hears no sounds during deflation. What should the nurse do next?✔✔Deflate the cuff completely and wait 1–2 minutes before repeating the measurement
A nurse is taking a manual blood pressure reading and hears the first Korotkoff sound at 130 mm Hg and the last at 78 mm Hg. What blood pressure should the nurse document?✔✔130/78 mm Hg
A client asks what the top number of a BP reading represents. What is the correct response?✔✔It represents the pressure in the arteries when the heart contracts
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A nurse uses a cuff that is too small for a client’s arm. How might this affect the reading?✔✔It may give a falsely high blood pressure reading
A nurse notes a client’s blood pressure has dropped significantly when moving from lying to standing. What is this condition called?✔✔Orthostatic hypotension
A nurse is assessing blood pressure in both arms. The readings differ by 12 mm Hg. What is the appropriate action?✔✔Use the arm with the higher reading for future measurements
A nurse hears the Korotkoff sounds fade and then return during BP measurement. What is this phenomenon called?✔✔Auscultatory gap
What is the best site to assess blood pressure in a client with a bilateral mastectomy?✔✔The thigh using the popliteal artery
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A nurse wants to ensure an accurate BP reading. What should be avoided 30 minutes prior to the measurement?✔✔Caffeine, exercise, and smoking
A nurse is preparing to take a client's BP. The client is talking and crossing their legs. What should the nurse do before measuring?✔✔Ask the client to sit quietly with legs uncrossed for 5 minutes
A nurse notes a BP reading of 90/52 mm Hg. What is the nurse’s first action?✔✔Assess for signs and symptoms of hypotension such as dizziness or faintness
A nurse is using an electronic BP monitor and receives an error message. What is the appropriate action?✔✔Retake the BP manually using a sphygmomanometer and stethoscope
A nurse must take a BP on a client who is on continuous IV infusion in the left arm. What should the nurse do?✔✔Use the right arm to avoid interfering with the infusion
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