The practical nurse (PN) is assisting with blood pressure measurement for adults at a community health fair. Which blood pressure measurement requires the most immediate action by the PN?

Choice A reason: A blood pressure measurement of 80/60 mm Hg is significantly low and may indicate hypotension, which can lead to symptoms such as dizziness, fainting, or shock. This requires immediate action to assess and manage the client's condition to prevent complications.
Choice B reason: A blood pressure measurement of 140/90 mm Hg indicates hypertension, which is a concern but does not require immediate emergency intervention. It requires follow-up and management to prevent long-term health issues.
Choice C reason: A blood pressure measurement of 130/85 mm Hg is considered elevated but not critically high. It is important to monitor and manage, but it does not require immediate emergency action.
Choice D reason: A blood pressure measurement of 120/90 mm Hg is slightly elevated diastolic pressure but not critically so. It is important to monitor, but it does not necessitate immediate emergency intervention.

Choice A reason: While respiratory rate is an important vital sign to monitor, changes in respiratory rate are not the most critical indicator of an imminent complication related to an abdominal aneurysm. Respiratory rate can be influenced by various factors such as pain, anxiety, or underlying respiratory conditions. However, it does not directly correlate with the risk of aneurysm rupture, which is the primary concern in clients with an abdominal aneurysm.
Choice B reason: Urinary output is an important indicator of renal function and overall fluid balance. However, changes in urinary output are not the most immediate concern in the context of an abdominal aneurysm. While it is essential to monitor urine output to ensure adequate kidney function, it is not the primary parameter that would signal an imminent complication or rupture of the aneurysm.
Choice C reason: Temperature can provide valuable information about the presence of an infection or systemic inflammation. However, changes in temperature are not directly related to the risk of aneurysm rupture. Although an elevated temperature may warrant further investigation, it is not the most critical finding to report in the context of an abdominal aneurysm.
Choice D reason: Blood pressure is the most important assessment finding to monitor and report in a client with an abdominal aneurysm. Elevated blood pressure can increase the risk of aneurysm rupture due to the added stress on the arterial wall. Conversely, a sudden drop in blood pressure can indicate a potential rupture or internal bleeding, which is a medical emergency. Monitoring and reporting changes in blood pressure are crucial in providing timely interventions to prevent or address complications related to an abdominal aneurysm.