Question

The unlicensed assistive personnel (UAP) tells the nurse the patient has a blood pressure of 78/46 and a pulse of 116 using a vital signs machine. Which action should the nurse implement first?

1- Notify the physician immediately.
2- Have the UAP re-check the patient's vital signs manually.
3- Assess the patient's cardiovascular status.
4- Place the patient in Trendelenburg position.

Answer 1

The nurse should first assess the patient's cardiovascular status to understand the patient's condition thoroughly before proceeding to more aggressive interventions or re-checking vital signs manually.

Step-by-step explanation:

When a Unlicensed Assistive Personnel (UAP) reports a blood pressure of 78/46 and a pulse of 116, the nurse should first assess the patient's cardiovascular status. This involves checking the patient's consciousness, skin temperature, color, capillary refill, and any presence of orthostatic changes. Immediate assessment will help determine the cause of the low blood pressure and tachycardia (high pulse rate) and decide if the patient is in urgent need of more aggressive interventions, such as notifying the physician or placing the patient in the Trendelenburg position.

Having the UAP re-check the patient's vitals manually is also important but can be done concurrently with the nurse's assessment to confirm the accuracy of the machine's readings. It is crucial to gather a comprehensive view of the patient's condition before proceeding with further steps such as notification of the physician or positioning changes.