The nurse is using a manual cuff to assess the blood pressure of a cli

The nurse is using a manual cuff to assess the blood pressure of a client experiencing hyperten-sion.

To best ensure accommodation for a possible auscultatory gap, the nurse should use which of the following as a guide for inflating the cuff appropriately?
1. Review the client’s chart for his last blood pressure reading.
2. Ask the client what his typical blood pressure reading is when taken manually.
3. Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated.
4. Take the client’s blood pressure both sitting and standing and use the higher reading.

ANSWER

ANS: 3
The examiner needs to be certain to inflate the cuff high enough to hear the true systolic pressure before the auscultatory gap. Palpation of the radial artery helps to determine how high to inflate the cuff. The examiner inflates the cuff 30 mm Hg above the pressure at which the radial pulse was palpated. Taking the blood pressure in various positions will not help eliminate the possible loss of auditory sound between the systolic and diastolic sounds. While asking the client and/or reviewing the chart may provide information concerning the client’s pressure, these options are not the recommended method for minimizing the effect of the auditory gap on the assessment process.