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?

Choice A rationale

Papules are raised, firm skin lesions often exceeding 0.5 cm in diameter. They are palpable and represent conditions such as warts or skin tags, differing from nonpalpable lesions described.

Choice B rationale

Vesicles are fluid-filled lesions with a diameter of less than 0.5 cm. They are palpable and typically associated with disorders like herpes simplex, not fitting the client's description.

Choice C rationale

Nodules are solid, elevated skin lesions larger than 0.5 cm in diameter. Unlike the client’s lesion, nodules extend into the dermis or subcutaneous layer, which makes them distinguishable.

Choice D rationale

Macules are flat, nonpalpable lesions less than 0.5 cm in diameter. They are confined to the epidermis, and examples include freckles or petechiae, matching the given characteristics precisely.

Choice A rationale: Administering potassium supplements may be appropriate, but the nurse must first notify the provider to confirm the treatment plan. Unilateral administration without provider input could lead to incorrect dosing.

Choice B rationale: Notifying the provider of the laboratory results is the priority to ensure prompt medical evaluation and intervention. The provider will determine the appropriate course of action based on the client's clinical condition and lab results.

Choice C rationale: Encouraging the client to eat potassium-rich foods is not the initial action. Diet changes take time to affect potassium levels, and immediate intervention is required to address the hypokalemia.

Choice D rationale: Monitoring for signs of hyperkalemia is inappropriate since the client has low potassium levels. The priority is to manage hypokalemia and prevent further complications.