Prioritize your nursing interventions based on the vital signs.

When multiple abnormal readings are present, the nurse must prioritize interventions based on the urgency, potential for deterioration, and underlying cause. The principle of ABC (Airway, Breathing, Circulation), followed by temperature regulation and pain control, guides prioritization.

Rationale for correct answer:

B. Heart rate 130 beats/min, apical: A heart rate of 130 bpm is significantly elevated and may indicate compensatory response to fever, pain, dehydration, or underlying cardiac stress.

Rationale for incorrect answers:

A. Temperature 10B.4°F (39.1°C): This is a moderate to high-grade fever, likely contributing to the elevated HR and RR. The fever itself is not immediately life-threatening, but needs to be addressed with antipyretics.

C. Respiratory rate 25 breaths/min: Mild tachypnea may be a response to fever, pain, or anxiety, but could also signal early respiratory distress. Although not critically high, this rate warrants ongoing respiratory assessment.

D. BP 145/80: This is a mildly elevated systolic BP, possibly related to stress, fever, or pain. It is not immediately concerning in this clinical context

Take-home points:

• Always prioritize circulation and respiratory compromise first - HR and RR abnormalities can indicate early deterioration.
• Fever and elevated BP are important, but unless critical, they typically follow cardiac and respiratory concerns in priority.

According to guidelines like JNC 7 and ACC/AHA, consistent elevated readings over multiple visits are necessary to diagnose hypertension. Nurses play a vital role in recognizing abnormal readings, educating patients, and guiding appropriate follow-up to prevent long-term complications like stroke or heart disease.

Rationale for correct answer:

A. Follow-up measurements of blood pressure: A single elevated BP does not confirm a diagnosis of hypertension. The nurse should recommend rechecking BP on separate occasions, as per guidelines, to determine if the elevation is persistent.

Rationale for incorrect answers:

B. Immediate treatment by a physician: Immediate treatment is not warranted based on a single mildly elevated BP unless the patient is symptomatic or has evidence of organ damage.

C. Nothing, because the nurse considers this reading is due to anxiety: While anxiety (white-coat hypertension) may cause temporary elevation, it should not be assumed without confirmation.

D. A change in dietary intake: Dietary changes (e.g., low sodium, DASH diet) are important in preventing or managing hypertension. However, before prescribing lifestyle changes, the first step is to confirm whether BP is consistently elevated.

Take-home points:

• A single reading of 130/90 mm Hg should prompt follow-up measurements, not immediate diagnosis or treatment.
• Nurses should avoid assumptions and use evidence-based protocols to guide BP assessment and education.