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.
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