A nurse receives a report from an assistive personnel that a client's blood pressure is 160/95 mm Hg. Which of the following actions should the nurse take first?

A. Report the finding to the provider. While the provider should be informed if the hypertension is new, persistent, or symptomatic, the nurse should first verify the blood pressure before escalating the concern.

B. Compare the finding to the client's blood pressure baseline. Checking the baseline is important, but the first action should be to confirm the accuracy of the reading by rechecking it. If the reading is consistent with previous values, the nurse can then compare it to the baseline.

C. Administer antihypertensive medications as prescribed. Administering medication without confirming the blood pressure reading could lead to unnecessary treatment or hypotension if the reading was inaccurate. The nurse should first recheck the BP.

D. Recheck the client's blood pressure. Rechecking the blood pressure ensures accuracy before making clinical decisions. Factors such as incorrect cuff size, client positioning, or transient increases (e.g., anxiety or pain) could cause an elevated reading. If the elevated BP is confirmed, then further action (e.g., notifying the provider or administering medication) can be taken.

A. Mix the medications together and administer through the NG tube. Incorrect because medications should be given separately to prevent drug interactions and ensure each is fully delivered.

B. Crush the sublingual medication into powder form. Incorrect because sublingual medications are designed to be absorbed through the oral mucosa, not the gastrointestinal tract. Crushing them negates their intended action.

C. Dissolve crushed tablet medications in sterile water. Sterile water is preferred for dissolving medications because it reduces the risk of bacterial contamination and prevents potential drug interactions that may occur with other fluids.

D. Flush the tube with 5 mL saline between each medication. Incorrect because a minimum of 15-30 mL of water is recommended between medications to prevent tube blockage.