Question

The nurse is obtaining vital signs on a stable client using an electronic blood pressure cuff. The cuff begins to inflate, but the machine is making an unusual sound. The client states that it is painfully tight. Which of the following actions is appropriate?

Remove the cuff from the client and take note of which device is defective

Remove the device from service and call biomedical services to provide maintenance

Obtain the blood pressure with the device and then report the issue to the charge nurse

Ask another nurse to assist in troubleshooting the device and obtain the blood pressure

Answer 1

The correct action when facing an issue with a blood pressure cuff causing pain is to remove the cuff from the client, take the device out of service, and call biomedical services for maintenance.

Step-by-step explanation:

When a nurse encounters an issue with a blood pressure cuff during routine vital sign checks, the most appropriate action to take if the client reports pain due to the cuff inflating too tightly and unusual sounds are heard from the machine, would be to remove the cuff immediately for the client's safety.

Subsequently, the device should be taken out of service to prevent potential harm to other patients, and the biomedical services should be alerted for necessary maintenance and inspection of the equipment. It's crucial to prioritize patient comfort and safety over completing the measurement at that time. Using a faulty device could lead to incorrect readings and potentially harm the patient.