A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following?
A. Seating the client with arm bared, supported, and at heart level.
B. Measuring the blood pressure after the client has been seated quietly for 5 minutes.
C. Using a cuff with a rubber bladder that encircles at least 80% of the limb.
D. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.
Correct Answer: D. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.
BP should be taken with the client seated with the arm bared, positioned with support, and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding the measurement. First, the patient should be questioned regarding recent caffeine consumption, exercise, or smoking. If any of these activities have occurred within the last 30 minutes, blood pressure measurement should be postponed until this period has passed.
Option A: If a manual measurement is being performed, the bell or diaphragm of a stethoscope should be placed over the medial antecubital fossa over the approximate location of the brachial artery. The blood pressure cuff should be inflated 30 mm Hg beyond the point at which the radial pulse is no longer palpable.
Option B: The client should rest quietly for 5 minutes before the reading is taken. The patient should be encouraged to empty his/her bladder. Upon return, the patient should be seated in a quiet room on a chair with back support. Both feet should be flat on the floor with the legs uncrossed, and this seated position should be maintained for at least 5 minutes.
Option C: The cuff bladder should encircle at least 80% of the limb being measured. Gauges other than a mercury sphygmomanometer should be calibrated every six (6) months to ensure accuracy. At this time, a properly sized cuff should be placed directly over the patient’s arm, no clothing should be underneath the cuff, and sleeves should not be rolled above the cuff. Once the cuff is in position, the patient’s arm should be supported so that the middle of the cuff is at the level of the right atrium.
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