After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistant. With this in mind, what clinical decision should the nurse make?
a. Administer scheduled medications assuming she would have been informed if the vital signs were abnormal.
b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return.
c. Ask the nursing assistant to record the patient's vital signs before administering medications.
d. Omit the vital signs because the patient is presently in no distress.
ANS: C
The nurse should ask the nursing assistant to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action.
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