A patient returned from a procedure and has vital sign measurements ordered every hour. The patient's blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What action by the nurse is most appropriate?
a. Take the vital signs again in another hour.
b. Document the findings in the patient's chart.
c. Have another nurse recheck the vital signs.
d. Plan to take the vital signs more often.
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.
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