A spouse assists the nurse evaluating the measurement of the client’s

A spouse assists the nurse evaluating the measurement of the client’s blood pressure. The nurse feels additional teaching is required if the spouse is observed:

1. Deflating the cuff at 2 mm Hg/second
2. Having the client sit down for the measurement
3. Using the same time each day for the measurement
4. Taking the blood pressure after the client comes back from a walk

ANSWER

ANS: 4
The client’s blood pressure should not be measured after the client has exercised, smoked, or in-gested caffeine. The client should wait 30 minutes before assessment of the blood pressure.
The cuff should be deflated at a rate of 2 mm Hg per second. When possible, the client should be sitting in a chair. The blood pressure should be assessed at the same time each day.