What action should the nurse take to avoid recording a low systolic blood pressure when there's an auscultatory gap?

When assessing blood pressure, an auscultatory gap refers to a period during which no sound is heard while listening through the stethoscope as the cuff pressure is released. This can lead to an inaccurate reading, specifically a falsely low systolic blood pressure. To ensure that the nurse accurately captures the systolic blood pressure when an auscultatory gap is present, it is crucial to inflate the cuff sufficiently above the last palpable radial pulse.

By inflating the cuff at least another 30 mm Hg after losing the pulse, the nurse ensures that the cuff pressure is high enough to account for the gap and obtain an accurate reading once sounds reappear. This practice helps prevent the error of recording a systolic pressure that is lower than the actual value, which is essential for proper patient assessment and treatment planning.

In this context, the other suggested actions do not effectively address the issue of the auscultatory gap in the same way. For instance, inflating the cuff 20 mm Hg above the radial pulse may not provide enough pressure to bypass the gap, while documenting a low reading and retaking it later does not correct the potential for miscalculation at the time of the initial assessment. Checking blood pressure in both arms at once does not directly correlate