Exam Cram NCLEX RN Practice Questions - Nurselytic

Correct Answer: D

Rationale: When selecting the correct blood pressure cuff size, it is essential to ensure that the width of the rubber bladder equals 40% of the circumference of the person's arm. This ensures proper fitting and accurate readings. The length of the bladder should actually equal 80% of the arm circumference, not 80% of the width, making choices B and C incorrect.
Choice A stating that the standard cuff size is appropriate for all sizes is inaccurate, as using an incorrectly sized cuff can lead to inaccurate blood pressure readings.

Correct Answer: C

Rationale: Mean Arterial Pressure (MAP) is the pressure that forces blood into the tissues, averaged over the cardiac cycle. It is not the pressure of the arterial pulse (
Choice
A), nor does it directly reflect the stroke volume of the heart (
Choice
B). While MAP involves systolic and diastolic pressures, it is not simply an average of these two values as diastole lasts longer. Instead, MAP is closer to diastolic pressure plus one third of the pulse pressure. The best description of MAP is that it represents the pressure forcing blood into the tissues, averaged over the cardiac cycle.

Correct Answer: C

Rationale: When measuring blood pressure, it's important to account for the possibility of an auscultatory gap, which occurs in about 5% of individuals, particularly those with hypertension due to a noncompliant arterial system.
To detect an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears. This ensures an accurate measurement of blood pressure by overcoming the potential gap in sounds.
Choice A is correct as it follows this guideline.

Choices B and C are incorrect because inflating the cuff to 200 mm Hg or above the patient's pulse rate does not address the specific issue of an auscultatory gap.
Choice D is incorrect as it focuses on the patient's previous readings rather than the current measurement technique needed to detect an auscultatory gap.

Correct Answer: B

Rationale: The correct answer is, 'The change in blood pressure readings is called orthostatic hypotension.' Orthostatic hypotension is defined as a drop in systolic pressure of ³20 mm Hg or ³10 mm Hg drop in diastolic pressure that occurs with a quick change to a standing position. This condition is common in individuals on prolonged bed rest, older adults, those with hypovolemia, or taking specific medications. The blood pressure readings provided in the question (150/90 mm Hg lying, 130/80 mm Hg sitting, and 100/60 mm Hg standing) demonstrate a significant change in blood pressure with position changes, which is indicative of orthostatic hypotension.

Choices A, C, and D are incorrect because the readings do not indicate a normal response or blood pressure within normal limits for the patient's age; rather, they suggest the presence of orthostatic hypotension.

Correct Answer: B

Rationale: Aging causes a decrease in vital capacity and decreased inspiratory reserve volume. As a result, the examiner may observe a shallower inspiratory phase and an increased respiratory rate in older adults. Contrary to common belief, the increased rigidity of arterial walls actually makes the pulse easier to palpate in aging adults. Pulse pressure is widened, not decreased, due to changes in systolic and diastolic blood pressures. Furthermore, changes in the body's temperature regulatory mechanism make older individuals less likely to develop a fever but more susceptible to hypothermia.