The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?
Explanation & Rationale
A. Record a palpable systolic pressure of 90 mm Hg is premature because the nurse has not yet completed the process of determining the systolic blood pressure. B. Inflate blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse disappears to ensure accurate measurement of the systolic blood pressure. C. Release the manometer valve immediately would not allow the nurse to accurately determine the systolic blood pressure. The valve should be released slowly to palpate the return of the pulse. D. Document the absence of the radial pulse is unnecessary because the disappearance of the pulse is a normal part of the procedure when obtaining a systolic blood pressure by palpation.