Question

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? A) Auscultate the blood pressure at the dorsalis pedis artery B) Measure the blood pressure with the client sitting on the side of the bed C) Place the cuff 7.6 cm (3 in) above the popliteal artery D) Place the bladder of the cuff over the posterior aspect of the thigh

Answer 1

To measure blood pressure in a client's lower extremity, a nurse should place the cuff tightly around the thigh, centered over the popliteal artery on the back of the knee, and use a stethoscope to listen for Korotkoff sounds as the cuff is deflated.

Step-by-step explanation:

When a nurse is obtaining blood pressure in a client's lower extremity, the proper technique would involve the following steps: The nurse should wrap an inflatable cuff tightly around the patient's thigh with the center of the bladder of the cuff positioned over the popliteal artery on the back of the knee. Then, while the client is lying down with their leg slightly bent, the nurse should place the stethoscope over the artery just below the cuff. The nurse would then inflate the cuff, raising pressure around the artery and temporarily occluding blood flow. As the cuff deflates, the nurse listens for the return of blood flow, known as the Korotkoff sounds, to determine systolic and diastolic pressures.

To specifically answer the student's options: Auscultating the blood pressure at the dorsalis pedis artery (A) would not be appropriate; this artery is located on the top of the foot and is not the correct location for measuring blood pressure in the lower extremity. Measuring the blood pressure while the client sits on the side of the bed (B) is not the ideal position for this measurement. The cuff should be placed over the posterior aspect of the thigh (D), covering the popliteal artery, not 7.6 cm (3 in) above it (C).

Answer 2

The correct answer would be:

C) Place the cuff 7.6 cm (3 in) above the popliteal artery.

When obtaining a blood pressure reading from a client's lower extremity, a nurse should adhere to specific steps to ensure accurate measurement:

1. Select the Appropriate Site:

The nurse should choose a site where the artery is close to the skin and over a firm surface, usually the popliteal artery at the back of the knee for the lower extremity.

2. Position the Client Correctly:

The nurse should have the client lie down with the leg flat and the thigh exposed. The client can also be seated with the leg in a bent position to expose the popliteal artery.

3. Place the Cuff Correctly:

The cuff should be placed around the thigh, with the center of the bladder of the cuff positioned over the popliteal artery, which is slightly medially and posteriorly on the back of the knee.

4. Auscultate at the Correct Location:

To auscultate, the nurse should place the stethoscope over the popliteal artery, just below the edge of the cuff.

Based on these steps, let's analyze the provided options:

A) Auscultate the blood pressure at the dorsalis pedis artery:

This is not the standard practice for measuring blood pressure in the lower extremity; the popliteal artery is the usual site.

B) Measure the blood pressure with the client sitting on the side of the bed:

This position can be used if the leg is positioned to expose the popliteal artery, but lying down is typically preferred for comfort and to ensure the leg is at heart level.

C) Place the cuff 7.6 cm (3 in) above the popliteal artery:

Placing the cuff above the artery ensures that the bladder of the cuff is over the artery when inflated.

D) Place the bladder of the cuff over the posterior aspect of the thigh:

This is the correct method for placement as it allows for proper auscultation of the popliteal artery.

Given these considerations, the correct answer would be:

C) Place the cuff 7.6 cm (3 in) above the popliteal artery.

This ensures that the cuff is in the correct position to compress the artery and obtain an accurate blood pressure reading from the lower extremity.