The nursing instructor is observing the student nurse take a blood pressure on an older adult client. The nursing instructor intervenes when the student nurse is observed doing which of the following? Standard Text: Select all that apply
1. The student nurse ushers the client into the exam room and immediately assesses the client's blood pressure.
2. The student nurse places the blood pressure cuff on the client's arm over a lightweight, long-sleeved sweater.
3. The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure.
4. The student nurse has the client sit in a chair and supports the client's arm on a table at the level of the heart.
5. The student nurse places the blood pressure cuff on the thigh of a client with a bilateral mastectomy and takes the blood pressure using the popliteal artery.
1,2,3
Rationale 1: The student nurse ushers the client into the exam room and immediately assesses the client's blood pressure. The client should sit quietly for at least 5 minutes before the blood pressure is taken. Immediately assessing the blood pressure after a client walks from the waiting room to exam room may not yield an accurate reading.
Rationale 2: The student nurse places the blood pressure cuff on the client's arm over a lightweight, long-sleeved sweater. The client's blood pressure should be assessed on a bare arm. If the client is wearing a long sleeved garment and it can be pushed up without constricting the arm, this is acceptable; otherwise the arm should be removed from the sleeve.
Rationale 3: The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure. Once the cuff is inflated and the nurse identifies the palpatory systolic blood pressure, the nurse should wait at least 15–30 seconds before inflating the cuff again.
Rationale 4: The student nurse has the client sit in a chair and supports the client's arm on a table at the level of the heart. In order to obtain an accurate blood pressure, the client should be seated with the arm slightly flexed, supported at the level of the heart with palm facing up.
Rationale 5: The student nurse places the blood pressure cuff on the thigh of a client with a bilateral mastectomy and takes the blood pressure using the popliteal artery. Clients who have suffered trauma to the upper extremities, have shunts in the upper extremities, or have had mastectomies should not have their blood pressures assessed on the affected sides. The nurse can place the blood pressure cuff on the thigh and assess the blood pressure using the popliteal artery.
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