67.4k views
5 votes
The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention? a. Ask the client to demonstrate self-blood pressure assessment. b. Provide the client with a larger blood pressure cuff. c. Recommend lower sodium in the client's diet. d. Report readings to primary care provider.

User Kesha
by
9.3k points

1 Answer

1 vote

Answer:

Option A, ask the client to demonstrate self-blood pressure assessment

Step-by-step explanation:

The nurse should prioritize asking the patient to demonstrate their blood pressure assessment because the reading contains one high measurement but another that is within expected limits.

A blood pressure (BP) reading of 150/90 is not necessarily an alarming reading. The diastolic pressure -- the denominator in the fraction denoting the blood pressure as the heart relaxes, its chambers fill with blood, and it prepares for another contraction -- is within normal limits; it should range between 80-100mmHg. The systolic pressure, however -- the numerator in the fraction denoting the blood pressure as the heart maximally contracts to propel blood to the peripheral tissues -- is quite high; the range here is typically 120-140mmHg.

Because of this discrepancy, the nurse would want to assess the patient's skill in performing the task, addressing errors that can affect the reading as they appear and providing the proper patient education to correct them.

Why Not the Other Choices:
The priority intervention should not be to provide a larger BP cuff because reading is being obtained incorrectly, the measurement may be even more inaccurate with an ill-fitted cuff.

Though recommending the patient implement a lower-sodium diet may help with blood pressure altogether, it would not resolve improper technique.

Lastly, as mentioned above, the reading is not severely or critically abnormal and, thus, does not warrant alerting the provider. When the blood pressure suddenly becomes higher than 180/120 without error in its measurement, the provider should be called because a hypertensive crisis may be taking place.

Conclusion:
In short, with a reading like this taken by the patient themselves, the nurse should prioritize identifying a potential knowledge deficit in self-monitoring blood pressure by having the patient demonstrate their technique (Option A) before implementing other interventions.

User Nicks
by
7.8k points

No related questions found