A nurse has delegated to a student nurse to obtain vital signs for a newly admitted client. The student reports the following: temperature = 37.4 °C, respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. To validate the data, the best action by the nurse is to:

Question

Quizplus · Accepted Answer

The high blood pressure reading of 200/146 needs to be validated as it could indicate a potential health concern. The nurse should reassess the blood pressure to ensure accuracy before taking any further action. Reporting to the Clinical Nurse Consultant or calling the physician may not be necessary at this point until further assessment is completed. Continuing with the physical assessment without rechecking the vital signs may lead to an incomplete or inaccurate assessment.

A Nurse Has Delegated to a Student Nurse to Obtain