A nurse obtains a blood pressure of 88/54 mmHg, but the patient is talking and moving the arm during measurement. What should the nurse do first?
Correct answer: B. Ask the patient to rest and repeat the measurement correctly
- A. Document the reading as confirmed hypotension
- B. Ask the patient to rest and repeat the measurement correctly
- C. Administer a prescribed antihypertensive medicine
- D. Report the reading without obtaining another measurement
Explanation
Patient movement can make a blood pressure reading inaccurate, so the nurse should allow rest and repeat the measurement using correct technique. Validation of questionable data should occur before conclusions or interventions when the patient's condition permits.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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