A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client’s BP is 158/96 mm Hg. Which of the following actions should the nurse take?
A.
Request that another nurse check the client’s BP in 30 min.
B.
Reposition the client supine and recheck her BP.
C.
Recheck the client’s BP in her other arm for comparison.
D.
Ensure that the width of the BP cuff is 50% of the client’s upper arm circumference
The correct answer and Explanation is :
The correct answer is:
C. Recheck the client’s BP in her other arm for comparison.
Explanation:
When a nurse records a blood pressure reading that is elevated, as in this case where the BP is 158/96 mm Hg, it’s important to ensure the accuracy of the measurement before taking further steps. Elevated blood pressure readings may be due to a variety of factors, including incorrect cuff placement, patient position, or even a single high reading that may not represent the client’s usual blood pressure.
Here’s why option C is the best course of action:
- Confirm Accuracy: Rechecking the BP in the other arm helps confirm whether the initial reading was accurate. Blood pressure readings can vary between arms, and significant differences might indicate a problem that requires further investigation. A discrepancy between arms may suggest a need for further evaluation.
- Rule Out Measurement Error: Sometimes, a single high reading might be due to a temporary issue such as stress or improper measurement technique. By checking the other arm, the nurse can determine if the reading was an isolated incident or part of a pattern.
- Follow Protocols: Medical protocols often include rechecking BP readings if the first measurement is abnormal. This ensures that any action taken is based on accurate and reliable data.
Option A, requesting another nurse to check the BP in 30 minutes, may not be the best initial step because it delays confirming the accuracy of the reading and addressing any potential issues immediately.
Option B, repositioning the client supine, is not generally recommended unless specific indications or conditions require it. Typically, BP measurements are taken with the client seated with their arm at heart level, so changing positions without addressing potential measurement errors might not be helpful.
Option D is related to the proper cuff size for accurate measurement but doesn’t address the immediate need to confirm the reading accuracy. Ensuring that the cuff fits correctly is important but should be part of a standard practice, and rechecking in the other arm provides additional verification.