A nurse is obtaining a client’s manual blood pressure and is having difficulty auscultating sounds.
Which of the following actions should the nurse take?

This method involves feeling the radial pulse while inflating and deflating the cuff.

The systolic pressure is estimated by noting the pressure at which the pulse disappears and reappears. The diastolic pressure is not measured by this method, but it can be useful when the sounds are difficult to hear.

Choice A is wrong because applying the largest cuff available can result in a falsely low reading. The cuff size should be appropriate for the client’s arm circumference.

Choice C is wrong because placing the arm above the level of the client’s heart can also cause a falsely low reading. The arm should be at the level of the heart for an accurate measurement.

Choice D is wrong because deflating the cuff quickly can lead to missing or skipping sounds, resulting in an inaccurate reading. The cuff should be deflated slowly and evenly.

Normal ranges for blood pressure vary depending on age, sex, and health conditions, but generally, a systolic pressure below 120 mmHg and a diastolic pressure below 80 mmHg are considered normal for adults.

The correct answer is choice D: A client who is taking warfarin and has an INR of 1.8.

Choice A rationale:

A Mantoux test with an induration after 48 hours can be a normal reaction, especially if the induration is within the expected size range for a positive result, depending on the individual’s risk factors and history. It does not necessarily require follow-up care unless the induration is significantly large or there are other concerning symptoms.

Choice B rationale:

A client scheduled for a colonoscopy and taking sodium phosphate does not typically require follow-up care for the sodium phosphate intake itself. Sodium phosphate is commonly used as a bowel prep medication to clear the intestines prior to the procedure.

Choice C rationale:

A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L), so a client taking bumetanide with this potassium level would not typically require follow-up care for the potassium level alone.

Choice D rationale:

A client taking warfarin with an INR of 1.8 requires follow-up care because the therapeutic range for warfarin is typically between 2.0 and 3.0 for most indications. An INR of 1.8 may indicate that the blood is not “thin” enough, increasing the risk of thrombotic events, and the warfarin dose may need adjustment.