A nurse is caring for a client who is flushed and has a temperature of 38.7° C (101.7° F). Which of the following actions should the nurse take?

Choice A reason: Requesting that the caller contact the client’s provider directly for information is not the best action. The nurse should first determine if the caller has the client’s consent to receive information and if the caller is authorized to do so.

Choice B reason: Asking the caller to contact the client directly for information is not appropriate. The client may not be able to communicate or may not want to share information with the caller. The nurse should respect the client’s privacy and confidentiality.

Choice C reason: Gathering additional information from the caller to verify their identity is the most appropriate action. The nurse should ask the caller for their name, relationship to the client, and other details that can confirm their identity. The nurse should also check the client’s record for any written or verbal consent to disclose information to the caller.

Choice D reason: Providing the caller with a brief update about the client’s condition is not advisable. The nurse should not share any information without verifying the caller’s identity and the client’s consent. The nurse should also follow the provider’s office policy and the Health Insurance Portability and Accountability Act (HIPAA) guidelines for disclosing information.

Choice A reason: Using a narrower cuff to repeat the BP measurement is an incorrect action by the nurse, as it can result in a falsely high reading. The nurse should use a cuff that fits the client's arm size and circumference.

Choice B reason: Measuring the client's BP in the other arm is the correct action by the nurse, as it can help to confirm the accuracy of the reading and rule out any possible errors or variations. The nurse should compare the readings from both arms and report any significant differences to the provider.

Choice C reason: Deflating the cuff faster when repeating the BP measurement is an incorrect action by the nurse, as it can result in a falsely low reading. The nurse should deflate the cuff at a rate of 2 to 3 mm Hg per second.

Choice D reason: Requesting a prescription for an antihypertensive medication is an inappropriate action by the nurse, as it is premature and unnecessary. The nurse should first verify the BP reading and identify the possible causes of the elevation, such as pain, anxiety, or medication effects. The nurse should also implement nonpharmacological interventions, such as positioning, relaxation, and oxygen therapy, before administering any medication.