Asked by Bobert Torres on May 25, 2024
Verified
The nurse is caring for a patient with the following vital signs:
Temperature: 98.9° F
Pulse: 94
Respirations: 20
Blood pressure: 144/94
Pulse oximetry: 94%
What is the priority action of the nurse?
A) Apply a cool washcloth to the patient's forehead.
B) Administer oxygen at 2 L/minute via nasal cannula.
C) Ask the patient about his usual blood pressure results.
D) Document the findings in the patient's medical record.
Blood Pressure
A measure of the force exerted by circulating blood on the walls of blood vessels, typically measured in millimeters of mercury (mmHg).
Pulse Oximetry
A non-invasive method to measure the oxygen saturation level of the blood.
Nasal Cannula
A lightweight tube used to deliver supplemental oxygen or airflow to a patient in need of respiratory help.
- Identify the appropriate action to take in response to abnormal vital signs readings.
Verified Answer
RY
Renielle YankanaJun 01, 2024
Final Answer :
C
Explanation :
The nurse must know the patient's usual range of vital signs in order to make appropriate judgments for care.A patient's usual values sometimes differ from the standard range for that age or physical state.Use the patient's usual values as a baseline for comparison with findings taken later.A single measurement does not adequately reflect a patient's blood pressure.Blood pressure trends,not individual measurements,guide nursing interventions.
Learning Objectives
- Identify the appropriate action to take in response to abnormal vital signs readings.