While caring for a client with hypertension, the nurse notes the following vital signs, BP of 140/90 mm hg, pulse- 120 , respirations-36, and temperature-100.8 degree Fahrenheit. The nurse's initial action should be to?

1. A

   Call the doctor

2. B

   Recheck the vital signs

3. C

   Obtain arterial blood gases

4. D

   Obtain an ECG

Appeared in: RAK Nursing Officer - 2019

Explanation

• The first step of the nursing process is Assessment, which includes validating any abnormal data collected.
• Rechecking vital signs ensures the accuracy of the readings before escalating care or notifying the healthcare provider.
• This action helps differentiate between a true change in the patient's clinical condition and potential errors from equipment, improper technique, or transient patient factors (e.g., recent activity, anxiety).
• According to nursing principles, assessment and validation must precede intervention.

Why Other Options Were Wrong

• Option A: Calling the doctor is a premature action. The nurse must first confirm that the vital signs are accurate before reporting them to avoid providing misinformation.
• Option C: This is an invasive diagnostic test that is not warranted as an initial step based on these vital signs alone. It is used to assess for hypoxemia and acid-base imbalances.
• Option D: This is a diagnostic test that is not the immediate priority without specific cardiac symptoms.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Prioritization of nursing actions based on the nursing process for a client with abnormal vital signs helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• Validating data is a fundamental patient safety measure. Acting on erroneous data can lead to unnecessary tests, incorrect treatments, and potential patient harm.
• Accurate reporting to a provider is crucial for effective collaboration. Reporting unverified data can damage professional credibility and lead to flawed clinical decision-making.
• What if? If the patient also reported crushing chest pain along with these vital signs, the initial priority would shift. The nurse should immediately call for help, notify the provider (or activate a rapid response team), and obtain an ECG as per chest pain protocol, while another team member simultaneously rechecks vitals.

How to Approach the Question

• First, identify the core of the question: it asks for the initial nursing action, which is a classic prioritization question.
• Recall the steps of the nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). The first and most fundamental step is always Assessment.
• Analyze the provided data: The patient has multiple abnormal vital signs (tachycardia, tachypnea, fever, and elevated BP).
• Evaluate the options in the context of the nursing process. 'Recheck the vital signs' is an assessment/validation step.
• Recognize that the other options ('Call the doctor,' 'Obtain ABG,' 'Obtain an ECG') are interventions or further diagnostic actions that should only occur after the initial assessment data has been validated.
• Conclude that validating the abnormal data is the correct and safest first step before proceeding to any other action.

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing actions based on the nursing process for a client with abnormal vital signs.
• Stem keywords: hypertension, vital signs, BP 140/90, pulse 120, respirations 36, temperature 100.8, initial action
• Lead-in keywords: initial action
• Clinical cues: The combination of tachycardia, tachypnea, and fever can indicate an underlying issue like an infection, which can also elevate blood pressure.
• Negative lead-in flag: false

Question ID

QlpdkdqRXYaFOqgNi6XT53

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 3 p. 33-35

E6 Nursing Vital Signs p. 86-88

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 3 p. 105-107