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A nurse on a busy medical-surgical floor has a certified nursing assistant assigned to her patients. The nurse has delegated to the CNA to obtain patient vital signs. The CNA reports to the nurse a blood pressure reading of 82/40 on a patient with atrial fibrillation. The nurse should do which of the following first? 

Explanation

•Many hospital floors have CNAs trained to obtain and record patient vital signs. This does not diminish or eliminate the nurse's responsibility for patient care regarding vital signs assessment. The CNA has the responsibility to report any abnormal vital signs to the nurse. The nurse then has the responsibility to verify the results.

•In patients with atrial fibrillation, blood pressures that are taken with a machine are often inaccurate due to the patient's irregular heart rhythm. In this instance, the nurse should reassess the BP with a manual BP cuff to verify the accuracy of the result, and then notify the doctor if the BP is still out of the expected range.

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