A portable electronic BP reading shows 186/110 mm Hg twice. What should the nurse do first?

A portable electronic BP reading shows 186/110 mm Hg twice. What should the nurse do first?

• A. Ask Mr. Brown to lie down and relax and then take the blood pressure again.
• B. Retake the blood pressure with a manual device.
• C. Find out from Mr. Brown which antihypertensive medication he takes.
• D. Replace the batteries in the electronic monitor.

Answer: (B)

When an automated BP reading is markedly high, the first step is to verify the measurement with a manual auscultated reading. Automated devices can give inaccurate results due to cuff size, patient position, movement, or device error. Use a properly sized cuff, have the patient seated with back supported and arm at heart level, and auscultate the brachial artery to obtain systolic and diastolic values. If the manual reading confirms hypertension, escalate care per protocol; if it does not, document the discrepancy and continue careful monitoring. Resting or asking about medications doesn’t by itself confirm accuracy, and replacing batteries is only relevant if the device is failing.

When an automated BP reading is markedly high, the first step is to verify the measurement with a manual auscultated reading. Automated devices can give inaccurate results due to cuff size, patient position, movement, or device error. Use a properly sized cuff, have the patient seated with back supported and arm at heart level, and auscultate the brachial artery to obtain systolic and diastolic values. If the manual reading confirms hypertension, escalate care per protocol; if it does not, document the discrepancy and continue careful monitoring. Resting or asking about medications doesn’t by itself confirm accuracy, and replacing batteries is only relevant if the device is failing.