The postoperative patient returned to the surgical nursing unit at 1:30 p.m. The evening shift nurse receives the report and begins working at 3:30 p.m. How often will the evening shift nurse take this patient's vital signs?

Question

a. Immediately, then every 30 minutes for the next 2 hours
b. Immediately, then every hour for the next 4 hours
c. Every hour beginning 30 minutes from now until end of shift
d. Immediately, then every 30 minutes 2 more times, then hourly

Answer 1

D
Vital signs would have been taken every 15 minutes for the first hour (1:30 to 2:30), then every 30 minutes for the next 2 hours (2:30 to 4:30). It is now 3:30, so the nurse will take vital signs immediately, again at 4:00, and again at 4:30, at which time the nurse can begin to take hourly vital signs if the patient's vital signs are within acceptable and stable range. Vital signs would have been taken every 15 minutes for the first hour (1:30 to 2:30), then every 30 minutes for the next 2 hours (2:30 to 4:30); therefore, "immediately and every 30 minutes for the next 2 hours" is incorrect (on that schedule, the nurse would be taking VS at 3:30, 4:00, 4:30, 5:00, and 5:30). It is too soon to begin hourly vital signs. At this time, the patient should be assessed more often than every hour.