It would be appropriate to delegate the taking of vital signs of which client to unlicensed assistive personnel?
A client being prepared for elective facial surgery with a history of stable hypertension
A client receiving a blood transfusion with a history of transfusion reactions
A client recently started on a new antiarrhythmic agent
A client who is admitted frequently with asthma attacks
The Correct Answer is A
According to the ANA and NCSBN guidelines, UAPs can take vital signs in stable clients, but the nurse is still responsible for interpreting the findings and taking action when needed. For clients who are unstable, newly admitted, or receiving high-risk treatments, vital signs should be taken by the nurse to allow for immediate clinical judgment.
Rationale for correct answer:
A. A client being prepared for elective facial surgery with a history of stable hypertension: This client is clinically stable and undergoing a planned, non-emergency procedure. The history of stable hypertension implies no acute instability, making it appropriate for the UAP to collect vital signs.
Rationale for incorrect answers:
B. A client receiving a blood transfusion with a history of transfusion reactions: This client is high risk due to a known history of transfusion reactions. Vital signs need to be monitored closely and frequently by a licensed nurse who can recognize early signs of a reaction.
C. A client recently started on a new antiarrhythmic agent: Starting a new antiarrhythmic introduces potential for serious adverse effects, including bradycardia, hypotension, or arrhythmias.
D. A client who is admitted frequently with asthma attacks: Although this client may be familiar to the unit, frequent asthma exacerbations place them at risk for acute respiratory deterioration. Vital signs should be taken by the nurse to assess signs of distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A difference in blood pressure readings between arms can be a normal variation (up to 10 mm Hg) or a sign of vascular disease such as subclavian artery stenosis, aortic dissection, or peripheral arterial disease.
Rationale for correct answers:
B. Repeat the measurements on both arms using a stethoscope: The AP may have used an automated cuff, which can be less accurate in obese patients or those with arrhythmias.
E. Review the patient’s record for her baseline vital signs: Comparing with previous BP readings helps determine whether the difference is new, worsening, or chronic.
Rationale for incorrect answers:
A. Notify the health care provider immediately: A 12 mm Hg systolic difference may warrant further evaluation if persistent, but notifying the provider immediately is premature.
C. Ask the patient whether she has taken her blood pressure medications recently: BP medication doesn’t cause a discrepancy between the two limbs.
D. Obtain blood pressure measurements on lower extremities: Lower extremity BP may be needed if there is suspicion of aortic coarctation or severe vascular disease, but this is not routinely indicated for a 12 mm Hg arm difference.
Take-home points:
- A systolic BP difference of >10 mm Hg between arms should be manually verified and assessed in context of clinical history and baseline.
- Nurses must take a stepwise approach-recheck manually, gather history, review baseline-before escalating to a provider.
Correct Answer is B
Explanation
Accurate blood pressure (BP) measurement is a fundamental nursing skill. If the cuff is deflated too quickly, the nurse may miss the first Korotkoff sound (systolic BP) or inaccurately estimate diastolic pressure. Deflating the cuff too slowly can cause venous congestion, discomfort, and a falsely high diastolic reading. Best practice guidelines recommend a cuff deflation rate of 2–3 mmHg per second to ensure an accurate reading without patient discomfort.
Rationale for correct answer:
B. 30–45 seconds: This is the recommended time frame for releasing the cuff when using a 2–3 mmHg/second deflation rate, which allows clear identification of both systolic and diastolic sounds.
Rationale for incorrect answers:
A. 10–20 seconds: Deflating the cuff this quickly equates to a deflation rate that is too fast (greater than 5 mmHg per second). This may result in missing Korotkoff sounds and underestimating the true BP values, especially systolic pressure.
C. 1 -- A.5 minutes: Deflating the cuff this slowly would equate to less than 1 mmHg per second, which is unnecessarily prolonged. It can cause venous congestion, discomfort, and may lead to a falsely elevated diastolic pressure.
D. 3–C.5 minutes: This is excessively slow and not clinically appropriate.
Take-home points:
- The blood pressure cuff should be deflated at a rate of 2-3 mmHg per second, resulting in a total release time of approximately 30-45 seconds, depending on the pressure range.
- Incorrect deflation rates (too fast or too slow) can lead to inaccurate readings and impact clinical decisions.
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