A nurse has delegated to a nurse's aide to obtain vital signs for ...

[segrsyd]

A nurse has delegated to a nurse's aide to obtain vital signs for a newly admitted client. The aide reports the following: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146.
 
  To validate the data, the best action by the nurse is:
  1. Retake the vital signs.
  2. Call the physician.
  3. Continue with the physical assessment as soon as possible.
  4. Report the findings to the charge nurse.

Question 2

A nurse is working in the operating room with a client just prior to the procedure. While setting up for the procedure, the nurse notices that the client has become unresponsive and respirations have become shallow.
 
  What type of assessment would be necessary in this situation?
  1. Initial assessment
  2. Problem-focused assessment
  3. Emergency assessment
  4. Time-lapsed assessment

[frankwu0507]

Answer to Question 1

Correct Answer: 1
Rationale: Guidelines for validating assessment data that are out of normal range include repeating the measurements, using another piece of equipment as needed to confirm abnormalities, or asking someone else to collect the same data. In this situation, the nurse needs to be sure that the vital signs are accurate. Calling the physician and reporting the findings to the charge nurse before they have been validated would be premature. The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated.

Answer to Question 2

Correct Answer: 3
Rationale: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems. Initial assessment is performed within a specific time after admission to a health care agency. Problem-focused assessment is an ongoing process integrated with nursing care. Time-lapsed assessment occurs several months after the initial assessment to compare the client's current status to baseline data previously obtained.

[segrsyd]

TY

[frankwu0507]

You're welcome