The nurse delegates the measurement of vital signs on three clients to unlicensed assistive personnel (UAP). The nurse evaluates the UAP's performance and notes that blood pressure is measured on a client by having the client hold the arm hanging over the side of the bed. Which is the priority action by the nurse?

Question

1. Commend the UAP for following the proper procedure.
2. Inform the charge nurse that the UAP does not know how to measure blood pressures.
3. Yell at the UAP and tell her she is incompetent.
4. Instruct the UAP that blood pressure should be measured with the artery at or above the level of the heart, and demonstrate correct technique.

Answer 1

4
Rationale 1: The nurse would not commend the UAP for proper technique, because blood pressure measurement performed with the artery lower than the heart will give a false reading.
Rationale 2: Telling the charge nurse transfers the responsibility held by the nurse delegating the procedure to another team member, and would not be the best choice.
Rationale 3: Yelling at a team member is never correct, and would be highly unprofessional.
Rationale 4: The nurse is responsible for teaching the UAP how to measure vital signs properly in a professional manner. Demonstrating proper technique is far more effective than just discussing it.
Global Rationale: The nurse is responsible for teaching the UAP how to measure vital signs properly in a professional manner. Demonstrating proper technique is far more effective than just discussing it. The nurse would not commend the UAP for proper technique, because blood pressure measurement performed with the artery lower than the heart will give a false reading. Telling the charge nurse transfers the responsibility held by the nurse delegating the procedure to another team member, and would not be the best choice. Yelling at a team member is never correct, and would be highly unprofessional.