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While measuring a patient’s blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? (Select all that apply.)
A. client is sitting with his leg crossed
b. the patient supports his or her own arm during the BP reading
c. the blood pressure cuff is too narrow for the extremities
d. the cuff is loosely wrapped around the arm
e. the arm is held above the level of the heart
f. the nurse does not inflate cuff high enough
When assessing the circulation to the lower leg of a client who has had knee surgery. Which action should the nurse take?
A. check the patient pedal pulses using the fingertips
b. feel for the temperature of the foot
c. visually inspect the color of the foot
d. compress the nail beds to determine capillary refill time

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