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?

Appeared in: DHS 2018 shift 1st

Explanation

The patient's vital signs, particularly the severe tachypnea (36 breaths/min) and tachycardia (120 bpm), indicate acute physiological distress.
The nurse's primary responsibility after identifying critical assessment data is to report it promptly to the healthcare provider for further medical orders.
This action is a crucial step in the nursing process, falling under implementation/communication, and is essential to prevent a 'failure to rescue' situation.
Delaying notification to perform other actions could lead to a rapid decline in the patient's condition.

Option B: While rechecking can be useful for questionable readings, a respiratory rate of 36 is a clear and critical sign of distress. Delaying reporting to re-measure wastes valuable time.
Option C: Obtaining Arterial Blood Gases (ABGs) is an invasive diagnostic procedure that requires a physician's order. It is not an independent nursing action that can be performed initially.
Option D: An electrocardiogram (ECG) is a diagnostic test that requires a physician's order. The nurse cannot initiate it independently as a first step.

Clinical Relevance

Nursing practice connection: Knowing Prioritization of nursing actions in response to critical changes in vital signs helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Promptly recognizing and reporting critical changes in vital signs is a core nursing competency essential for patient safety and preventing adverse outcomes.
This scenario highlights the nurse's role in the chain of communication. Failure to escalate care by promptly notifying the provider can lead to significant patient harm.
In any healthcare setting, the nurse is often the first to detect a change in patient status. This ability to assess, identify a problem, and report it is fundamental to safe practice.

How to Approach the Question

First, analyze the clinical data provided. Identify all vital signs and note which are outside the normal range for an adult (Normal: Pulse 60-100, Respirations 12-20). Here, pulse (120), respirations (36), and temperature (100.8°F) are abnormal.
Assess the severity of the abnormalities. A respiratory rate of 36 is severely high and indicates significant respiratory distress, which is a priority concern.
Identify the question type. It asks for the 'initial action,' which makes it a prioritization question.
Evaluate the options based on the nursing scope of practice and urgency. Ask yourself: 'Can I do this independently?' and 'Is this the most important first step?'.
Eliminate options that require a doctor's order (obtaining ABGs, obtaining an ECG).
Compare the remaining options. Rechecking vitals delays action, whereas calling the doctor initiates the process for getting necessary medical interventions. Therefore, reporting the critical findings is the priority.

Concept Tested & Keywords

Concept Tested: Prioritization of nursing actions in response to critical changes in 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: Pulse 120 bpm (tachycardia) and Respirations 36/min (severe tachypnea) are critical findings indicating acute distress.
Clinical cues: The combination of fever, tachycardia, and tachypnea suggests a serious underlying condition like infection (sepsis) or a pulmonary event.

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E6 Nursing Fundamentals Potter Perry 12e Part 3 pp. 54-56, 33-35

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

Practise the full DHS 2018 shift 1st

Attempt every question from this paper in a timed mock, then review the full solution for each one.