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    Hesi compass B exit proctored exam
    Select All That Apply

    The nurse measures the client's blood pressure (BP) and notes that it is significantly higher than the previous reading. What intervention(s) should the nurse implement next? Select all that apply.

    Explanation & Rationale

    A. Determining recent activity or emotional state can explain a transient BP increase. B. Retaking the BP in the opposite arm helps confirm accuracy and identify possible vascular issues. C. Waiting an hour for reassessment may delay important intervention. D. Apical-radial pulse deficit assessment is related to cardiac arrhythmias, not immediate BP discrepancies. E. Taking multiple readings immediately on the same arm may cause discomfort and anxiety, potentially affecting accuracy; it is better to wait a few minutes between measurements.

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