A nurse has delegated to a nurse’s aide to obtain vital signs for a ne

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.

ANSWER

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.