A registered nurse asks an unlicensed assistive person to obtain vital signs on a stable client. The blood pressure is much lower than the previous reading. What should the nurse do first?
Correct answer: B. Ask the assistant to repeat the measurement while the nurse observes
- A. Ask the assistant to document the reading and continue rounds
- B. Ask the assistant to repeat the measurement while the nurse observes
- C. Tell the assistant to encourage the client to drink more fluids
- D. Wait until the next scheduled vital-sign check to compare readings
Explanation
The nurse should validate an unexpected finding promptly, while also assessing the client for possible deterioration. Documentation, fluid advice, or delaying reassessment does not address the immediate safety concern.
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About Delegation and Assignment (NCLEX)
Delegation and assignment cover how the registered nurse allocates care according to patient stability, task complexity, staff competence and legal scope. The five rights of delegation, supervision, communication and follow-up are linked to the difference between an RN, LPN or LVN, and unlicensed assistive personnel, while accountability for overall nursing care remains with the RN.
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50 free Delegation and Assignment (NCLEX) MCQs from International Nursing Practice, each with the correct answer and an explanation. Unlimited attempts, no account needed.
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