The nurse is assessing a client’s blood pressure to establish a baseli

The nurse is assessing a client’s blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data:

1. Reflect a normal variation
2. Should be reported to the client’s health care provider
3. Dictate that pressure should be monitored in the left arm
4. Indicate that the client may be experiencing vascular problems

ANSWER

ANS: 2
During the initial assessment, obtain and record the blood pressure in both arms. Normally there is a difference of 5 to 10 mm Hg between the arms (Lane and others, 2002). In subsequent as-sessments, measure the blood pressure in the arm with the higher pressure. Pressure differences greater than 10 mm Hg indicate vascular problems and are reported to the health care provider or nurse in charge. Reporting the assessment findings is the most appropriate outcome.