Question

A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

a) Inflate the cuff 10 mm Hg above the point where sounds are no longer heard.
b) Deflate the cuff rapidly and reinflate to obtain an accurate reading.
c) Place the bell of the stethoscope over the brachial artery.
d) Record the absence of sounds as diastolic pressure.

Answer 1

The nurse should place the bell of the stethoscope over the brachial artery to more accurately detect Korotkoff sounds for blood pressure measurement.

Step-by-step explanation:

When a nurse encounters difficulty auscultating sounds during a manual blood pressure reading, they should take several standardized steps to ensure accurate measurement. The correct course of action, among the options provided, is to place the bell of the stethoscope over the brachial artery. This is because the brachial artery is typically the best location to detect the Korotkoff sounds that are indicative of systolic and diastolic pressures. The cuff should be inflated to a pressure above the systolic pressure to stop blood flow, then released slowly. As the cuff deflates, the first Korotkoff sound indicates the systolic pressure, and when these sounds disappear completely, it indicates the diastolic pressure. Option "c" correctly suggests repositioning the stethoscope rather than manipulating the pressure in the cuff in various incorrect ways or wrongly recording a measurement.