Question

a nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood - pressure machine. the nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. which of the following actions should the nurse take? turn on the machine every 15 min to measure the clients blood pressure. record only blood pressure readings needed for the 15 - min intervals. obtain manual and automatic readings and compare them. disconnect the machine and measure the blood pressure manually every 15 min.

Explanation:

When an electronic blood - pressure machine is malfunctioning (measuring at varied intervals and giving inconsistent readings), the most appropriate action for the nurse is to ensure accurate and reliable measurements. Manually measuring the blood pressure is the best way to do this for a client who is unstable and requires regular monitoring. Turning on the machine at set intervals does not address the machine's malfunction, recording only selected readings does not ensure accuracy, and comparing manual and automatic readings while the automatic machine is malfunctioning may not provide useful information.

Answer:

D. Disconnect the machine and measure the blood pressure manually every 15 min