A nurse obtains an electronic blood pressure reading of 188/96 mm Hg. Which action should the nurse take next?

• A. Provide client teaching regarding medications to control blood pressure.
• B. Notify the provider of the client's blood pressure reading.
• C. Provide client education on measures to decrease blood pressure.
• D. Obtain a manual blood pressure reading from the client.

Answer: (D)

When a reading from an electronic BP device is markedly high, first verify its accuracy with a manual measurement. Automated machines can overestimate or underestimate BP because of cuff size, arm position, movement, recent activity, caffeine or nicotine use, or device fault. Using a properly sized cuff on a calm, rested patient and auscultating with a stethoscope confirms whether the elevated value is real. If the manual reading is still high, you would then notify the provider and follow the unit’s protocol. If the manual reading is not elevated, you would adjust care accordingly. Providing medication or education about BP comes after confirming the reading and any orders are in place.