A client returns to the room after a physical therapy session. The client has a cast on the right arm. The nursing assistant takes the blood pressure (BP) and notes the reading is 160/90 mm Hg, which is higher than the client's previous reading. What is the appropriate action for the nursing assistant to take?

Question

Quizplus · Accepted Answer

The nursing assistant observes that the BP is elevated above previous readings, so the BP needs to be retaken instead of reporting the finding to the nurse immediately. The best action is to wait 5 minutes before rechecking the BP on the left arm so the BP will be accurate. The right arm is in a cast, so the BP should not be taken on that arm as doing so may cause tissue damage. Retaking the blood pressure with a smaller cuff will not be effective, as there is no indication that the cuff size caused the higher reading. A cuff that is too large will elicit a reading that is too low, and a cuff that is too small will elicit a reading that is too high.

A Client Returns to the Room After a Physical Therapy