What action taken by a nursing assistant when measuring blood pressure warrants intervention by a nurse?

What action taken by a nursing assistant when measuring blood pressure warrants intervention by a nurse?

• A. Using a cuff that encircles at least 60% of the limb
• B. Measuring blood pressure after a client drinks coffee
• C. Encouraging the client to relax
• D. Allowing the client to talk during the measurement

Answer: (B)

Measuring blood pressure after a client drinks coffee is a situation that requires intervention because caffeine can temporarily elevate blood pressure. Coffee is a stimulant that increases heart rate and may cause a transient rise in blood pressure, which can lead to inaccurate readings. To ensure that blood pressure measurements are valid and reflect the client's typical baseline level, it's best practice to measure blood pressure when the client has been resting and without recent intake of caffeine or other stimulants. This helps create a more accurate and reliable assessment of the client’s cardiovascular status. In contrast, using a cuff that encircles at least 60% of the limb is important for obtaining an accurate measurement, and encouraging the client to relax helps reduce anxiety that can affect blood pressure. Allowing the client to talk during the measurement is not ideal, as it can also lead to fluctuations in readings, but it is not as critical as the impact of prior caffeine consumption.

Measuring blood pressure after a client drinks coffee is a situation that requires intervention because caffeine can temporarily elevate blood pressure. Coffee is a stimulant that increases heart rate and may cause a transient rise in blood pressure, which can lead to inaccurate readings. To ensure that blood pressure measurements are valid and reflect the client's typical baseline level, it's best practice to measure blood pressure when the client has been resting and without recent intake of caffeine or other stimulants. This helps create a more accurate and reliable assessment of the client’s cardiovascular status.

In contrast, using a cuff that encircles at least 60% of the limb is important for obtaining an accurate measurement, and encouraging the client to relax helps reduce anxiety that can affect blood pressure. Allowing the client to talk during the measurement is not ideal, as it can also lead to fluctuations in readings, but it is not as critical as the impact of prior caffeine consumption.