A patient has a blood pressure of 150/88 mmHg after talking continuously during the measurement. The patient feels well. What should the nurse do next?
Correct answer: B. Repeat the measurement after quiet rest
- A. Diagnose hypertension from this single reading
- B. Repeat the measurement after quiet rest
- C. Give an antihypertensive medicine immediately
- D. Measure the pressure over the patient’s clothing
Explanation
Talking can raise or alter a blood pressure reading, so the nurse should allow the patient to rest quietly and repeat the measurement using proper technique. A single reading does not establish a diagnosis or justify immediate medication without a prescription and clinical assessment.
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About Vital Signs and Monitoring
Vital signs include temperature, pulse, respiration, blood pressure, oxygen saturation and pain assessment. Coverage includes correct measurement sites and techniques, normal adult ranges, factors that alter readings, trends in patient observations, and the difference between an abnormal finding that needs reassessment and one requiring immediate reporting.
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