Question

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistant. With this in mind, what clinical decision should the nurse make?

A. Administer scheduled medications assuming she would have been informed if the vital signs were abnormal.
B. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return.
C. Ask the nursing assistant to record the patient's vital signs before administering medications.
D. Omit the vital signs because the patient is presently in no distress.

Answer 1

The nurse should ask the nursing assistant to record the patient's vital signs before administering any medications, as they are critical to assessing the patient's current health status and ensuring safe care.

Step-by-step explanation:

In a clinical setting, especially under the direct supervision of a registered nurse, it's crucial to ensure that all necessary patient information, including vital signs, is recorded before proceeding with further medical interventions. Vital signs are fundamental measures of a patient's health status and can highlight whether immediate action is required. Hence, the appropriate clinical decision for the nurse in this scenario would be:Option C: Ask the nursing assistant to record the patient's vital signs before administering medications.

This action is crucial because vital signs serve as primary indicators of the patient's current health and can influence treatment decisions. Administering medications without this information could pose a risk if the patient's vital signs are abnormal. For instance, certain medications may have adverse effects if given to a patient with low blood pressure or an elevated heart rate unknown to the healthcare provider. Therefore, the nurse should always prioritize patient safety by ensuring that a complete and accurate set of vital signs is available to inform clinical decisions.