After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?
Explanation & Rationale
A. An auscultatory gap is a period of silence that occurs between systolic and diastolic sounds (often seen in hypertensive patients). You cannot confirm a gap exists until you have completed the entire deflation and noted if sounds disappear and then reappear. B. Since the nurse already heard a Korotkoff sound, the stethoscope is correctly placed over the brachial artery. Moving it now would interrupt the reading. C. When performing manual blood pressure measurement, the transition from silence to the first rhythmic tapping sound indicates the systolic blood pressure (Phase I of Korotkoff sounds). Hearing silence followed by a clear sound after the valve has been released is the expected progression of the procedure. D. Reinflating the cuff immediately on the same arm can cause venous congestion, leading to an inaccurate (falsely high) diastolic reading. If a reading must be repeated, the nurse should deflate the cuff completely and wait 1 to 2 minutes before trying again.