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: PGIMER Chandigarh NO - 2015

Explanation

• The fundamental principle of the nursing process (ADPIE) dictates that Assessment is the first step.
• Assessment includes validating any data that is abnormal or inconsistent with the patient's expected condition.
• Rechecking the vital signs ensures the accuracy of the readings before escalating care or implementing interventions.
• Factors such as patient anxiety, recent physical activity, pain, or equipment error can cause transient or false elevations in vital signs.
• Validating the data allows the nurse to provide an accurate report to the healthcare provider and make sound clinical judgments.

Why Other Options Were Wrong

• Option A: Calling the doctor is an implementation step that should occur after the nurse has completed a thorough assessment and validated the abnormal findings.
• Option C: Obtaining arterial blood gases (ABGs) is an invasive procedure and is not indicated as an initial response to an elevated respiratory rate alone.
• Option D: Obtaining an ECG is a specific diagnostic test for cardiac issues and is not the first step for tachycardia without other cardiac symptoms.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Nursing process and initial action for abnormal vital signs helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• Validating abnormal vital signs is a critical patient safety measure to prevent misdiagnosis and inappropriate treatment.
• Accurate assessment and reporting are hallmarks of professional nursing practice and are essential for effective interdisciplinary communication.
• What if the patient was also complaining of crushing chest pain? In that scenario, the priority shifts. While one nurse rechecks vitals, another should simultaneously activate the emergency response system (or call the doctor STAT) and bring an ECG machine to the bedside. The situation changes from 'validate data' to 'act on a life-threatening symptom'.

How to Approach the Question

• First, identify the core of the question, which asks for the 'initial action'. This signals a question about priorities.
• Next, analyze the data provided: a full set of abnormal vital signs (hypertension, tachycardia, tachypnea, fever).
• Recall the systematic problem-solving method for nursing: the Nursing Process (ADPIE).
• Recognize that 'Assessment' is always the first step. An essential part of assessment is validating your data, especially when it's abnormal.
• Evaluate the options in light of this principle. 'Recheck the vital signs' is a validation action (Assessment). The other options ('Call the doctor', 'Obtain ABGs', 'Obtain an ECG') are interventions or further diagnostic steps (Implementation) that should follow a confirmed assessment.
• Therefore, select the option that represents data validation as the correct initial action.

Concept Tested & Keywords

• Concept Tested: Nursing process and initial action for abnormal vital signs.
• Stem keywords: hypertension, vital signs, BP 140/90, pulse 120, respirations 36, initial action
• Lead-in keywords: initial action
• Clinical cues: A full set of abnormal vital signs (BP, pulse, respirations, temperature) indicating a systemic issue.
• Negative lead-in flag: false

Question ID

QzfUlHjMYMMZmkDkQ1AIVs

Copy ID

Reference Book

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

E6 Nursing Vital Signs p. 86-88