When reaching over the side rails to take a client’s blood pressure, h

When reaching over the side rails to take a client’s blood pressure, he draws back. To promote effective communication, the nurse should first:

1. Tell the client that the blood pressure can be taken at a later time
2. Rotate the nurses who are assigned to take the client’s blood pressure
3. Continue to perform the blood pressure assessment quickly and quietly
4. Apologize for startling the client and explain the need for touching the client

ANSWER

ANS: 4
Nurses often have to enter a client’s personal space to provide care. The nurse should convey confidence, gentleness, and respect for privacy. This response demonstrates respect and provides information so the client can understand the need for personal contact. Telling the client that the blood pressure can be taken at a later time does not promote effective communication. Rotating the nurses who are assigned to take the client’s blood pressure impedes the nurse’s ability to form a therapeutic, helping relationship. Continuing to perform the procedure quickly and quietly may send a negative nonverbal message. It also does not promote effective communication.