A patient’s blood pressure suddenly drops from 132/82 to 104/52. The nurse notes that the patient’s skin is pale and the patient appears ready to faint. What is the priority action of the nurse?

Choice A reason: This is an incorrect choice because using empathy is not the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Empathy is a communication technique that involves understanding and sharing the feelings of another person. However, it is not the term that describes the cognitive process of drawing conclusions from the available data.

Choice B reason: This is an incorrect choice because setting priorities is not the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Setting priorities is a nursing skill that involves determining the order of importance of the patient's problems and interventions. However, it is not the term that describes the cognitive process of drawing conclusions from the available data.

Choice C reason: This is the correct choice because making inferences is the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Making inferences is a critical thinking skill that involves reaching a logical judgment or assumption based on the available data and evidence. The nurse makes an inference that the patient is in pain based on the patient's nonverbal cues and the fact that the patient just had surgery.

Choice D reason: This is an incorrect choice because recognizing inconsistencies is not the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Recognizing inconsistencies is a critical thinking skill that involves identifying discrepancies or contradictions in the data or information. However, it is not the term that describes the cognitive process of drawing conclusions from the available data.

Choice A reason: This is incorrect. Documenting the finding in the patient’s medical record is an important step, but not the most appropriate first action of the nurse. The nurse should first confirm the irregularity by counting the apical pulse.

Choice B reason: This is incorrect. Assessing the brachial pulse for a pulse deficit is a useful technique, but not the most appropriate first action of the nurse. A pulse deficit is the difference between the apical and radial pulse rates. The nurse should first count the apical pulse before comparing it with the radial pulse.

Choice C reason: This is incorrect. Notifying the health care provider immediately is a necessary step, but not the most appropriate first action of the nurse. The nurse should first gather more information by counting the apical pulse and determining the type and severity of the irregularity.

Choice D reason: This is correct. Counting the patient’s apical pulse for one full minute is the most appropriate first action of the nurse. The apical pulse is the most accurate way to measure the heart rate and rhythm. The nurse should listen to the heart sounds at the apex of the heart, which is located at the fifth intercostal space, left midclavicular line. The nurse should count the number of beats and note any irregularities, such as skipped, extra, or uneven beats.