Question

The RN monitoring the procedure noted that the HR increased from 80-110 and the BP increased from 110/70 to 168/97. What is the most appropriate intervention?

a) keep monitoring VS every 5 minutes
b) it is okay because the patient is having surgery
c) inform the surgeon of the change in VS
d) both A and C

Answer 1

The most appropriate intervention when a patient's HR and BP increase significantly during a procedure is to keep monitoring vital signs every 5 minutes and to inform the surgeon of the changes.

Step-by-step explanation:

When a patient experiences a significant increase in heart rate (HR) and blood pressure (BP) during a procedure, it is crucial for the Registered Nurse (RN) to take appropriate actions. If the patient's HR increases from 80 to 110 bpm, and BP increases from 110/70 to 168/97 mmHg, the RN should consider that these changes may be indicative of a stress response, pain, anxiety, or other complication needing immediate attention.

Considering this, the most appropriate intervention would include both monitoring vital signs (VS) vigilantly and informing the surgeon of the change in the patient's status. Therefore, the correct answer is: d) both A and C, keep monitoring VS every 5 minutes and inform the surgeon of the change in VS. Continuous monitoring allows for the assessment of trends and timely identification of potential issues, while informing the surgeon ensures that the whole medical team is aware of the patient's status and can intervene if necessary.