Difficulty: Medium
Average Score: 66%
Simulated
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
Correct answer
B
Rationale
Measuring BP in the other arm confirms accuracy and rules out discrepancies; itÔÇÖs the first step. Choice A doesnÔÇÖt affect accuracy. Choice C risks false elevation; correct cuff size is key. Choice D is premature without verification.