A nurse is assessing a client's blood pressure and finds it to be 140/90 mmHg on multiple occasions. What action should the nurse take?

Answer: c. Initiate antihypertensive medication.

Explanation: A blood pressure reading of 160/90 mmHg indicates hypertension (high blood pressure). The nurse should initiate antihypertensive medication and implement other interventions as appropriate to manage and control blood pressure.

a. Documenting the blood pressure as normal would be inaccurate since it exceeds the normal range.

b. Rechecking the blood pressure after 30 minutes may delay appropriate intervention if the blood pressure remains elevated.

d. Instructing the client to increase salt intake is not appropriate for managing hypertension, as sodium intake can exacerbate high blood pressure.

Answer: c. Report the findings to the healthcare provider. Explanation: A significant difference in blood pressure readings between the two arms may indicate an underlying vascular or arterial problem. The nurse should report the findings to the healthcare provider for further evaluation and intervention.

a. Documenting the finding as a normal variation would be inappropriate since it may indicate an underlying vascular or arterial issue.

b. Rechecking the blood pressure using the arm with the higher reading may be considered, but reporting the findings to the healthcare provider is the priority for further evaluation.

d. Instructing the client to raise both arms above the head is not necessary and does not address the potential underlying issue with blood pressure readings in different arms.