Unlicensed assistive personnel measure a newly admitted client's vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data?
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.
Rationale 1: 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.
Rationale 2: Calling the physician would be premature.
Rationale 3: The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated.
Rationale 4: Reporting the findings to the charge nurse before they have been validated would be premature.
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