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?

Report the finding to the provider.

Compare the finding to the client's blood pressure baseline.

Administer antihypertensive medications as prescribed.

Recheck the client's blood pressure.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is B

Explanation

A. Decreased blood urea nitrogen (BUN): BUN typically increases with dehydration.

B. Increased hematocrit: Hemoconcentration occurs in dehydration, increasing hematocrit levels.

C. Decreased urine specific gravity: Dehydration typically causes an increase in urine specific gravity.

D. Increased calcium level: Calcium levels do not directly indicate fluid volume status.

A. Document shiny, taut skin as an expected finding. B. Perform palpation after auscultation. C. Listen for 1 min before documenting absent bowel sounds. D. Perform auscultation immediately after the client has consumed a meal.

Correct Answer is B

Explanation

A. Document shiny, taut skin as an expected finding. Shiny, taut skin may indicate ascites or fluid retention, which are abnormal findings.

B. Perform palpation after auscultation. Palpation should always follow auscultation to avoid altering bowel sounds.

C. Listen for 1 min before documenting absent bowel sounds. Bowel sounds are considered absent only after listening for at least 5 minutes in each quadrant.

D. Perform auscultation immediately after the client has consumed a meal. Post-meal auscultation may result in altered bowel sounds, making the assessment unreliable.

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