Evolve HESI Practice Exam

What is the most important action for the nurse to take when observing a UAP using a blood pressure cuff that is too small?

1. Document the blood pressure reading.

2. Reassess the client's blood pressure using a larger cuff.

3. Ask the UAP how often they have been trained.

4. Tell the UAP to stop taking vital signs.

The correct answer is: Reassess the client's blood pressure using a larger cuff.

Reassessing the client's blood pressure using a larger cuff is crucial because the size of the blood pressure cuff significantly impacts the accuracy of the reading. When a cuff that is too small is used, the measured blood pressure can be erroneously high, leading to misdiagnosis or inappropriate management of the client's condition. By taking the blood pressure again with a properly sized cuff, the nurse ensures that the data collected is accurate and reliable, allowing for appropriate clinical decisions to be made based on correct measurements. In clinical practice, accurate vital signs are essential as they inform the care plan and any necessary interventions. A vital sign such as blood pressure can indicate how well the heart is functioning and whether additional monitoring or treatment is needed. Therefore, the nurse’s priority is to verify the accuracy of the blood pressure reading by using an appropriate cuff size, ensuring patient safety and quality of care.