The nurse is caring for a patient admitted with hypovolemic shock.The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure.What is the best nursing action?
A) Assess the blood pressure by Doppler.
B) Estimate the systolic pressure as 60 mm Hg.
C) Obtain an electronic blood pressure monitor.
D) Record the blood pressure as "not assessable."

Question

Quizplus · Accepted Answer

Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction.If blood pressure is not audible,the approximate value can be assessed by palpation or ultrasound.If brachial pulses are palpable,the approximate measure of systolic blood pressure is 80 mm Hg.This action has the potential to delay further assessment of a compromised patient in shock.Documenting a blood pressure as not assessable is inappropriate without further attempts using different modalities.

The Nurse Is Caring for a Patient Admitted with Hypovolemic