The practical nurse (PN) is assisting with blood pressure measurement for adults at a community health fair. Which blood pressure measurement requires the most immediate action by the PN?

Choice A reason: Reinforcing the expected outcomes of surgery is important in the preoperative phase to ensure the client understands the procedure, risks, and expected results. However, once the IV sedative has been administered, the client may be in a sedated state and may not be able to retain this information effectively. Therefore, this action is more appropriate before administering the sedative rather than after. The focus should shift to monitoring the client's vital signs and ensuring their safety.
Choice B reason: Determining if the client needs to void is generally part of the preoperative preparations to ensure that the bladder is empty, reducing the risk of complications during the procedure. While it is important, this step should be completed before administering the sedative to ensure the client is alert and able to communicate their needs. Once sedated, the client’s immediate needs should focus on their vital signs and overall stability.
Choice C reason: Auscultating all lung fields is a valuable assessment to ensure the client has clear airways and adequate ventilation. However, once the client is sedated, continuous monitoring of vital signs, including respiration, is more critical. Auscultating lung fields might be appropriate before the procedure to establish a baseline, but it is not the immediate priority after administering sedation.
Choice D reason: Monitoring blood pressure is the most crucial action to implement after administering the IV sedative. Sedatives can cause changes in cardiovascular stability, including hypotension or hypertension. Continuous monitoring of blood pressure helps detect any adverse effects of the sedation and ensures prompt intervention if necessary. Maintaining stable blood pressure is vital for the safety and well-being of the client during and after the procedure.

Choice A reason: Using a large cuff to obtain BP readings on either thigh is the appropriate action. With a history of a right radical mastectomy, blood pressure should not be taken on the right arm due to the risk of lymphedema. The left arm is also not suitable due to the recent surgery and cast. Therefore, the thigh is the best alternative site for accurate BP measurement.
Choice B reason: Measuring all vital signs every 2 hours except the BP is not appropriate because BP is a critical vital sign that needs to be monitored regularly, especially in postoperative clients. Omitting BP measurements could miss important changes in the client's condition.
Choice C reason: Obtaining manual BP readings with a cuff on the left arm is not recommended as the client has a recent surgical repair and cast on the left arm. This can cause discomfort and may not provide accurate readings.
Choice D reason: Quickly releasing air from the BP cuff on the right arm is not suitable due to the client's history of right radical mastectomy. This practice could exacerbate the risk of developing lymphedema in the affected arm.