The nurse is preparing to assess blood pressure on a patient who has had two prior readings of 160/100. Physician's notes from a prior visit indicate that the patient is suspected to have hypertension
When reassessing this patient for hypertension, the nurse will do what? (Select all that apply.)
a. Instruct patient to sit on the exam table.
b. Choose a cuff encircling at least 80% of the arm.
c. Support patient's arm at heart level.
d. Encourage patient to sit quietly for 5 minutes before assessing blood pressure.
e. Instruct the patient that one more increased reading is required before hypertension is diagnosed.
ANS: B, C, D
An appropriately sized cuff bladder encircles at least 80% of the arm and is required for accuracy. The arm is supported at heart level. The individual should be seated quietly for at least 5 minutes in a chair with feet on the floor. Sitting on an exam table is not preferred. Feet should be on the floor. An elevated reading on two or more separate occasions after initial screening is considered hypertension.
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