The nurse determines that unlicensed assistive personnel (UAP) are not

The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision?

1. The valve on the bulb was closed.
2. The client was sitting with the legs crossed.
3. The arm was below the level of the heart.
4. The UAP waited 2 minutes before re-measuring.
5. The cuff bladder was placed over the brachial artery.

ANSWER

Correct Answer: 2, 3

Rationale 1: The valve on the bulb needs to be closed to pump up the cuff.

Rationale 2: The adult client should be sitting with both feet on the floor. Crossed legs can cause elevations in systolic and diastolic blood pressures.

Rationale 3: The elbow should be slightly flexed with the palm of the hand facing up and the arm supported at heart level. The blood pressure increases when the arm is below heart level.

Rationale 4: After taking a measurement, 1 to 2 minutes should transpire before making any further measurements.

Rationale 5: The cuff should be placed evenly around the upper arm and the bladder center placed directly over the artery.