During a routine assessment, a nurse notes a patient's heart rate is 120 bpm. What action should the nurse take?

In a situation where a nurse notes a heart rate of 120 beats per minute, the most appropriate action is to conduct a further assessment to identify possible underlying causes. A heart rate of 120 bpm is classified as tachycardia, which can be indicative of various medical conditions such as fever, anxiety, dehydration, or underlying cardiac issues.

Performing a thorough assessment allows the nurse to gather additional vital signs, evaluate the patient's symptoms, and potentially identify factors contributing to the elevated heart rate. This step is crucial in creating a comprehensive understanding of the patient's condition and determining the best course of action or intervention.

Ignoring the elevated heart rate could lead to missed opportunities for early intervention, especially if the tachycardia is a sign of a more serious problem. Similarly, merely checking blood pressure without further assessment does not provide a complete picture of the patient's health status. Documentation is essential, but it should follow an assessment that informs care decisions based on the patient's current condition. Thus, further assessment for potential causes stands out as the most responsible and efficient action in this scenario.