Vital Signs Assessment

2. Which actions are strictly a nurse's responsibility

- Assess patients to determine if medically stable. -Interpret vital sign measurements. - Report significant vital sign findings to the health care provider. - Reassess any unexpected vital sign values.

4. How frequently would the nurse assess vital signs for a patient with a head injury who suddenly reports a severe headache and whose blood pressure rises from 118/62 to 170/94

Every 5 minutes

1. Which response indicates a nurse has a correct understanding about the components of a vital sign assessment

Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart.

6. Which action would the nurse take when the unlicensed assistive personnel (UAP) reports the patient's pulse increased from 74 beats/min to 100 beats/min and the temperature increased from 99° to 101.8°F (37.2° to 38.8°C)

Reassess the patient.

9. Which vital sign finding indicates the adult patient is improving

Respiratory rate decreases from 36 to 20.

5. Which action would the nurse take for a stable patient who is scheduled for a transfer to the rehabilitation unit later in the afternoon

Take vital signs before the transfer

8. Which patient trend does the vital sign graphic indicate

The systolic blood pressure is rising slightly while the diastolic pressure is steady.

7. Which entries would the nurse include when documenting vital signs

o Date of assessment o Time of assessment o Numeric results of the assessment

3. Which actions are required for proper documentation of vital signs

o Documenting in a standardized format o Recording on a specified form

10. Which actions are responsibilities of the nurse when assigning vital signs to the unlicensed assistive personnel (UAP)

o Ensure that the UAP uses the proper technique for measuring vital signs. o Validate that the UAP knows what values need to be reported immediately for each patient. o Ensure that the UAP is competent to perform vital sign assessments. o Validate that the UAP uses appropriate equipment.