The unlicensed assistive personnel on the cardiac floor reports to the registered nurse that during the first vital sign measurement on the shift, a client's blood pressure measured 198/102 mm Hg on the automated blood pressure machine. What action should the nurse take first?

Question

Quizplus · Accepted Answer

This client's abnormally high blood pressure increases the risk for complications such as stroke. The nurse should assess this client and recheck the blood pressure with a manual cuff to verify the accuracy of the previous measurement taken by the unlicensed assistive personnel (UAP). The nurse will need to assess the client further before making additional nursing judgments and taking action. (Option A) The nurse should not instruct the UAP to perform additional blood pressure measurements as this client could have severe hypertension; delegation of such a task is inappropriate (does not fit the "right circumstances" for delegation). If the client's reading is not as high as previously thought after blood pressure measurement with a manual cuff, the nurse can then instruct the UAP to take subsequent measurements with a different automatic blood pressure machine. (Option B) The nurse may need to notify the health care provider but only after the client has been assessed further by the nurse. (Option C) The client's blood pressure must be verified for accuracy before administering a PRN antihypertensive. Educational objective: When the unlicensed assistive personnel (UAP) reports an abnormal vital sign to the nurse, the nurse should assess the client further. It is inappropriate delegation to have the UAP recheck the client.

The Unlicensed Assistive Personnel on the Cardiac Floor Reports to the Registered