Question

While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the alr valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

a. Reposition the stethoscope in the antecubital fossae over the palpable brachial pulse point.
b. Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading.
c. Inflate the cuff quickly to a higher mm of Hg reading than the previously auscultated systolic sound
d. Continue the blood pressure assessment until the last Korotkoff sound is heard.

Answer 1

The correct action is to release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading when loud Korotkoff sounds are immediately heard upon the initial inflation of the blood pressure cuff.

Step-by-step explanation:

When loud Korotkoff sounds are heard immediately after releasing the air valve on a sphygmomanometer, it indicates that the blood pressure cuff was not inflated high enough to occlude the brachial artery completely. The correct action for the nurse to take next is to inflate the cuff to 30 mm Hg above the client's previous systolic reading to ensure an accurate measurement.

In the given scenario, the best answer from the provided options would be:

• b. Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading.

Vital to the process are the Korotkoff sounds, which signal the systolic and diastolic pressures. The first Korotkoff sound indicates the systolic pressure, and the point where the last Korotkoff sound is heard represents the diastolic pressure. Hence, initially inflating the cuff to a pressure above the expected systolic pressure is critical to avoid underestimating the systolic pressure.