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?
A.
Deflate the cuff faster when repeating the BP measurement.
B.
Request a prescription for an antihypertensive medication.
C.
Use a narrower cuff to repeat the BP measurement.
D.
Measure the client’s BP in the other arm.
The Correct Answer and Explanation is:
The correct answer is D. Measure the client’s BP in the other arm.
Explanation:
When monitoring blood pressure (BP) in a postoperative client, significant fluctuations can occur due to various factors, including pain, anxiety, fluid shifts, or residual effects from anesthesia. In this scenario, the client’s BP has risen from 126/72 mm Hg to 176/96 mm Hg within a short period. This change represents a concerning increase in both systolic and diastolic pressures, indicating possible hypertension that warrants further investigation.
Rationale for Option D: Measuring the BP in the other arm is a prudent first step in this situation. Blood pressure readings can vary between arms due to anatomical differences or vascular issues. By comparing the BP in the other arm, the nurse can determine whether the elevated reading is consistent across measurements. If the BP in the other arm is significantly lower or within normal limits, it may suggest that the initial reading could be an anomaly rather than a true reflection of the client’s condition.
Rationale for Other Options:
- A. Deflate the cuff faster when repeating the BP measurement. This option is not appropriate, as deflating the cuff too quickly can lead to inaccurate readings. Proper technique is essential to ensure reliable measurements.
- B. Request a prescription for an antihypertensive medication. While an antihypertensive may be necessary if persistent hypertension is confirmed, the nurse should first verify the accuracy of the readings before escalating to medication interventions.
- C. Use a narrower cuff to repeat the BP measurement. Using a narrower cuff could lead to falsely elevated readings, especially in cases of hypertension. Proper cuff size is crucial for accurate BP measurement.
In summary, measuring the client’s BP in the other arm provides a valuable step in determining the accuracy of the elevated reading before deciding on further actions, such as medication management or additional assessments.