The nursing assistant informs the nurse that the patient's blood pressure is 220/102 using the electronic monitor. What is the priority action of the nurse?

A. Take the temperature for 6-8 minutes. Modern digital thermometers provide accurate readings within seconds to a minute, making such a long duration unnecessary.
B. Wear gloves throughout the procedure. Gloves must be worn to maintain infection control and hygiene, as rectal temperature measurement involves contact with mucous membranes and potential exposure to bodily fluids.
C. Place the patient in the prone position. The left lateral (Sims') position is the preferred position for rectal temperature measurement, as it provides better access and comfort.
D. Insert the thermometer 2.5 inches into the patient's anus. For adults, the correct insertion depth is 1.5 inches (3-4 cm), while for infants, it is only 0.5 inches (1.3 cm) to prevent injury.

A. Inform the patient's health care provider immediately to obtain an order for antihypertensive medications. While notifying the provider may be necessary, the nurse must first confirm the accuracy of the blood pressure reading before taking further action.
B. Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately. Nursing assistants can take blood pressure readings, but the nurse should personally verify a critically high reading using a manual method.
C. Take the patient's blood pressure manually with a sphygmomanometer and stethoscope. Electronic monitors can sometimes give false readings, especially in patients with irregular heartbeats or movement. Manually verifying ensures an accurate assessment before determining further action.
D. Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke. A neurological assessment is important if the elevated BP is confirmed, but the first priority is verifying the reading manually.