A patient returned from a procedure and has vital sign ...

[rmenurse]

A patient returned from a procedure and has vital sign measurements ordered every hour. The patient's blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What action by the nurse is most appropriate?
 
  a. Take the vital signs again in another hour.
  b. Document the findings in the patient's chart.
  c. Have another nurse recheck the vital signs.
  d. Plan to take the vital signs more often.

Question 2

A nurse notes a patient has abnormal vital signs. What action by the nurse is best?
 
  a. Document the findings.
  b. Notify the provider.
  c. Compare with prior readings.
  d. Retake the vital signs.

[leahm14]

Answer to Question 1

ANS: D
The nurse uses clinical judgment to determine how often the patient's vital signs should be checked when there is a change in patient condition. The nurse should plan to assess vital signs more often in this patient. Since this is a significant change, the nurse should not wait another hour even though this is what the provider prescribed. It is not necessary for another nurse to double-check the vital signs. Documentation needs to occur, but the priority is to plan to take the vitals more often.

Answer to Question 2

ANS: C
Individual vital signs are not as important as the trends. For instance, a patient may have a blood pressure higher than normal that is normal for the patient. Trends give more useful information than a single reading. Documentation is important, but the nurse needs to do more. If the readings are significantly abnormal, the provider should be notified. The nurse may retake the vital signs if he/she is not confident of the first set of measurements.

[rmenurse]

Both answers were spot on, thank you once again

[leahm14]

Great! Please up vote