How long should the nurse wait before taking again the clients blood pressure for accurate reading?

The nurse obtains a blood pressure on a client using a Doppler ultrasound device but is unsure if the results are accurate. The nurse plans to repeat the measurement. What step would the nurse take to ensure a correct reading?

Ensure that the cuff is completely deflated before attempting another reading.

Rationale: A Doppler ultrasound device amplifies the sound and is especially useful if the sounds are indistinct or inaudible with a regular stethoscope. If a reading is suspicious or inaccurate, the nurse should ensure that the cuff is completely deflated before attempting the measurement again. It is important to wait at least 1 minute between readings to allow normal circulation to return to the limb. Waiting 30 minutes would be inappropriate and potentially problematic, especially if the client's blood pressure is accurate and requires immediate intervention. Because the device is used when sounds are indistinct or inaudible, measuring the blood pressure by auscultation would be inappropriate. Unless it is loose, the cuff does not need to be reapplied.

A client's blood pressure is very low and the nurse needs to asses it using a Doppler. To get an accurate reading the nurse would inflate the cuff to what level on the manometer?

Where the pulse disappears

Rationale: Once the pulse is heard with the Doppler, the nurse would inflate the cuff while continuing to use the Doppler device on the artery. The cuff needs to be inflated to the point where the pulse can no longer be heard. This is the estimate of the systolic blood pressure. Using the Doppler device the nurse will only get the systolic measurement. It is not necessary to inflate the cuff to a certain level, because this will not give an accurate measurement of the blood pressure. Because the Doppler amplifies the sound of the pulse, lack of sound is used as the gauge to inflate the cuff.

What is most important for the nurse to do when using an automatic electronic device to obtain serial blood pressure readings?

Check that the cuff is deflated completely after the reading.

Rationale: With serial blood pressure readings, typically the cuff of the automatic electronic device remains in place. The nurse must make sure that the cuff completely deflates after the reading. Incomplete deflation of the cuff between measurements can lead to inadequate arterial perfusion and venous drainage, compromising the circulation in the limb. A Doppler ultrasound device uses a Doppler tip to assess pulse and estimate systolic blood pressure. The Doppler device tip, not the cuff of an automated electronic device, is lubricated with conducting gel.

When using a Doppler to obtain a client's blood pressure, which action does the nurse take?

Inflate the cuff until the pulse disappears.

RATIONALE: Only a systolic blood pressure can be obtained via ultrasound. The systolic number is determined by the occlusion and absence of the brachial pulse. Gel is placed on the client's pulse site, not directly on the Doppler tip. The blood pressure cuff bladder should be snug, not tight. No stethoscope is needed to obtain a blood pressure by Doppler.

A nurse is measuring a client's blood pressure using an electronic device. What is important for the nurse to do to ensure accurate results?

Check to make sure the client's heart rate is regular.

RATIONALE: Various factors such as an irregular heart rate, excessive client movement, and environmental noise can interfere with the accuracy of the readings obtained with an electronic blood pressure device. Therefore, the nurse should make sure that the client's heart rate is regular and take steps to minimize client movement and external noise. In addition, it is important that the cuff be applied to the arm so that no clothing interferes with its placement.

The nurse is giving instructions to the client about the procedure for measuring orthostatic hypotension. The nurse explains that for each measurement, the client will have to remain in the position for approximately how long?

3 minutes

RATIONALE: The time for each position is approximate, with 3 minutes being the common denominator in each position. The client can remain supine for 3 to 10 minutes prior to measurement, 1 to 3 minutes when sitting, and 2 to 3 minutes when standing.

The nurse will assess the client for orthostatic hypotension. What symptoms would alert the nurse that the client is experiencing hypotension? Select all that apply.

Pallor, Dizziness, Diaphoresis

RATIONALE: The symptoms of hypotension are dizziness, light-headedness, pallor, diaphoresis or syncope. These symptoms need to be assessed in each position the client is in for blood pressure measurement. Breathing problems and heart rate are not common symptoms of hypotension, although they can be a contributing factor.

The nurse is obtaining serial blood pressure measurements on a client having hypertension medication adjustment. What assessment is most important for the nurse to perform frequently?

Determine if there is compromised circulation in the limb.

RATIONALE: When using an automatic blood pressure device for serial readings, the nurse should check the cuffed limb frequently. Incomplete deflation of the cuff between measurements can lead to inadequate arterial perfusion and venous drainage, compromising the circulation in the limb. The client should be in a comfortable position but does have to remain completely still throughout the process. When blood pressure readings are obtained and they vary greatly from one reading to another, the nurse would need to check the client to see if there is movement, feelings of distress or syncope. The machine would also need to be checked for proper functioning. Widely fluctuating readings may be a sign of malfunction of the machine or some instability with the client. These are important assessments for the nurse, but they do not take priority over circulation compromise of the limb. The cuff should always be deflated between measurements.

The nurse is preparing to measure an adult's orthostatic blood pressure. Place the following steps of the procedure in the correct order. Use all options.

1)Assist the client into a supine position.
2)Wait 3 to 10 minutes, then measure the client's blood pressure.
3)Assist the client to the sitting position with legs dangling.
4)Wait 1 to 3 minutes, then measure the client's blood pressure.
5)Assist the client to a standing position.
6)Wait 2 to 3 minutes, then measure the client's blood pressure.

RATIONALE: To measure an adult's orthostatic blood pressure, do the following: 1) Assist the client into a supine position. 2) Wait 3 to 10 minutes, then measure the client's blood pressure. 3) Assist the client to the sitting position with legs dangling. 4) Wait 1 to 3 minutes, then measure the client's blood pressure. 5) Assist the client to a standing position. 6) Wait 2 to 3 minutes, then measure the client's blood pressure.

When preparing to measure orthostatic hypotension, the nurse should place the bed in which position?

The lowest position

RATIONALE: When measuring for orthostatic hypotension, lower the head of the bed to a flat position. Position the bed in the lowest position so that when client sits, up the feet can be placed on the floor and the lowest position allows for easier standing. This position also allows for maximum standing and an easier way to get the client back in bed if hypotension should occur. Raising the bed to the nurse's height provides an unsafe situation for the client if orthostatic hypotension should occur because it increases the chances of the client falling. Elevating the head of the bed will give inaccurate test results.

The nurse has completed assessing for orthostatic hypotension and documents the results. What results would indicate to the nurse the client is experiencing orthostatic hypotension?

A decrease in systolic pressure >20 mm Hg

RATIONALE: The blood pressure readings should be documented in all three positions (lying, sitting, and standing). A decrease in systolic pressure of >20 mm Hg or a decrease in diastolic pressure of >10 mm Hg would indicate orthostatic hypotension.

The nurse is assessing a client for orthostatic hypotension and is obtaining the blood pressure while the client is sitting at the edge of the bed with the feet dangling. The client states, "I'm feeling a bit dizzy." The client is pale and beginning to perspire. What should the nurse do first?

Have the client lie down in the bed.

If a client exhibits signs and symptoms of orthostatic hypotension, such as dizziness, lightheadedness, pallor, diaphoresis, or syncope, the nurse should immediately return the client to the supine position. The client should not stand if the symptoms occur when the client is sitting because there is a risk of falling. Placing the client's feet flat on the floor or raising the arms over the head would be inappropriate.

The nurse reads the client's history and notes the client has vascular insufficiency in one upper extremity and both lower extremities. Which device would be most appropriate for assessing the client's blood pressure?

Doppler ultrasound

RATIONALE: If a client has venous insufficiency, it may be difficult to hear the blood pressure. The Doppler ultrasound will help because it amplifies the sound. It is especially useful if the sounds are indistinct or inaudible with a regular stethoscope. Hemodynamic monitoring would be used if the client required continuous monitoring or was very ill in settings such as an ICU. A cuff on the forearm would not allow for sufficient sounds to be transmitted. An electronic monitor device measures sounds by pressure. If there is insufficient blood flow the machine would not be able to detect a correct blood pressure.

The nurse is teaching a class on vital signs to a group of new unlicensed assistive personnel (UAP). What should the nurse teach the UAP about the proper use of an electronic blood pressure machine when taking vital signs on an adult client? Select all that apply.

Select an adult setting on the machine
,
Wrap the cuff around the arm snugly
,
Line up the artery mark with limb artery

RATIONALE: The center of the bladder of the cuff should be placed over the artery, lining up the artery mark on the cuff with the limb artery to obtain an accurate reading. The cuff should be wrapped around the limb smoothly and snugly. No clothing should be under the cuff as it will interfere with proper positioning of the cuff and an inaccurate reading. The client should be in a comfortable position with the limb at or near heart level, not below. If the UAP is measuring blood pressure on an adult, the settings on the machine should be set to adult settings.

The nurse estimates a client's systolic pressure to be 150 mm Hg. When obtaining the client's blood pressure measurement with a sphygmomanometer, the nurse would inflate the cuff to which pressure?

180 mm Hg

RATIONALE: When measuring a client's blood pressure, the nurse inflates the cuff to a pressure 30 mm Hg above the estimated systolic pressure. Doing so ensures a period before hearing the first sound that corresponds to the systolic pressure and prevents misinterpreting phase II sounds as phase I sounds. The pressures below 180 mm Hg would all be too low.

The nurse is providing care to a client who has had a left modified radical mastectomy 2 days ago. The woman also has an intravenous line inserted in the right antecubital space. Which would be most appropriate when assessing this client's blood pressure?

Use either the client's right or left thigh to obtain the blood pressure.

RATIONALE: If a client has a mastectomy or catheters in the extremity, the blood pressure should not be measured in the affected extremity because of risk for lymphedema secondary to the mastectomy, and the risk of tissue and vessel injury or catheter damage secondary to the catheter placement. Since this client has an intravenous line in the right arm and had the mastectomy on the left, neither upper extremity would be appropriate to use. Instead the nurse should obtain a thigh blood pressure using either lower extremity. There is no need to notify the health care provider to obtain the blood pressure through an arterial device.

The client is experiencing a neuromuscular condition with frequent tremors. The nurse determines to manually check the client's blood pressure instead of using the electronic blood pressure machine. What is the rationale behind the nurse's decision?

The blood pressure machine would not be accurate.

RATIONALE: Electronic blood pressure devices are not recommended for clients with irregular heart rates, tremors, and the ability to hold the extremity still. The presence of these conditions may cause the monitor to incorrectly overinflate the cuff, causing pain for the client. The client's comfort and position are not as important as the accuracy of the reading. The nurse's preference is not a priority.

A nurse is measuring a client's blood pressure in the right arm and is having difficulty auscultating the sounds. Which would be least appropriate for the nurse to do?

Apply less pressure with the stethoscope

RATIONALE: Difficulty auscultating blood pressure sounds may be related to equipment, environmental noise, or inaccurate placement of the stethoscope. Appropriate actions would include applying firmer pressure to the stethoscope when it is placed at the brachial artery, rechecking the brachial artery pulse to ensure the proper placement of the stethoscope, checking to make sure that all equipment is functioning properly, making sure that the room is quiet, and trying the measurement on the opposite extremity.

The nurse must assess a client's systolic blood pressure using a Doppler ultrasound. Place the following steps to this procedure in the correct order. Use all options.

1)Center the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery.
2)Wrap the cuff around the limb smoothly and snugly and fasten it.
3)Place a small amount of conducting gel over the artery.
4)Place the Doppler tip in the gel and move it around until hearing the pulse.
5)Inflate the cuff while continuing to use the Doppler device on the artery.
6)Note the point on the gauge where the pulse disappears.

RATIONALE: To assess a client's systolic blood pressure using a Doppler ultrasound, the nurse would perform the following steps: 1) Center the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. 2) Wrap the cuff around the limb smoothly and snugly, and fasten it. 3) Place a small amount of conducting gel over the artery. 4) Place the Doppler tip in the gel and move it around until hearing the pulse. 5) Inflate the cuff while continuing to use the Doppler device on the artery. 6) Note the point on the gauge where the pulse disappears.

How long should you wait before taking another blood pressure reading?

How many times should I take my blood pressure to get an accurate reading?

How long should the nurse wait in between two blood pressure readings on the same arm?

Should you measure BP immediately again?