A nurse is assessing the blood pressure of a large adult client diagnosed with primary hypertension. To ensure an accurate blood pressure reading, the nurse follows which standard of care? Select all that apply
A) Use the large adult blood pressure cuff.
B) Place the cuff midway between the acromion and olecranon process.
C) Vary the blood pressure reading sites every other day.
D) Obtain supine, sitting, and standing readings daily.
E) Document the results immediately after the reading is completed.
A, B, E
Feedback:
Standards of care require that the nurse use the proper-sized blood pressure cuff placed at the proper location on the arm at the appropriate time. Using a large adult blood pressure cuff is the correct size. Placing the cuff between the acromion process and olecranon process is the correct site. Documenting the blood pressure reading accurately after obtaining the reading is correct. Varying the blood pressure site and positioning every 1 or 2 days provides varied readings. Consistency needs to be maintained to draw accurate conclusions.
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