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    Hesi compass B exit proctored exam

    The charge nurse observes an unlicensed assistive personnel (UAP) preparing to use a standard sized blood pressure cuff to measure the blood pressure of an adult client with thrombocytopenia. Which action should the charge nurse take?

    Explanation & Rationale

    A. Having the primary nurse measure vital signs is unnecessary unless there is a safety concern that cannot be corrected through education. B. Observing the technique may be useful in other situations, but here the priority is to address the risk related to the client’s condition before proceeding. C. Advising the UAP about the bleeding and bruising risk is essential because thrombocytopenia increases the risk of petechiae, hematomas, and excessive bleeding from cuff pressure. The UAP should be instructed to use the cuff gently and minimize pressure. D. Using a smaller cuff would not necessarily prevent injury and could lead to inaccurate blood pressure readings. Proper technique and awareness of the condition are more important.

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