Difficulty: Medium
Average Score: 66%
Simulated
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?
Correct answer
C
Rationale
The correct answer is C: Recheck the client's BP in her other arm for comparison. This is the best course of action because taking the BP in the other arm can help determine if the reading is accurate or if there is an issue with the equipment or technique. It is important to rule out any potential errors before taking further action.
Choice A is incorrect because waiting 30 minutes may not address the potential issue with the BP reading. Choice B is incorrect because the width of the cuff should be appropriate for the arm size, not a specific percentage of the arm circumference. Choice D is not necessary unless there are specific reasons to suspect positional effects on BP readings.
Choice A is incorrect because waiting 30 minutes may not address the potential issue with the BP reading. Choice B is incorrect because the width of the cuff should be appropriate for the arm size, not a specific percentage of the arm circumference. Choice D is not necessary unless there are specific reasons to suspect positional effects on BP readings.