The nurse is caring for a patient with an arterial monitoring system.The nurse assesses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg.The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg.What is the best action by the nurse?
A) Activate the rapid response system.
B) Place the patient in Trendelenburg position.
C) Assess the cuff for proper arm size.
D) Administer 0.9% normal saline bolus.

Question

Quizplus · Accepted Answer

Under normal circumstances,a difference of 10 to 20 mm Hg or more between invasive and noninvasive blood pressure is expected,with the invasive value being higher than the noninvasive value.The cuff used for noninvasive measurement should be assessed for proper cuff size.Given that the invasive value is substantially higher,before initiating corrective actions based on a single noninvasive measurement,such as activating the rapid response system,placing the patient in Trendelenburg position,or administering a fluid bolus,further assessment and troubleshooting are necessary.

The Nurse Is Caring for a Patient with an Arterial