Which of the following is an unexpected finding that should be documented and reported to the provider?

Choice A reason: A blood pressure of 90/60 mmHg is hypotensive, indicating potentially inadequate perfusion to organs, which may result from dehydration, shock, or medication effects. This reading is concerning and requires reporting to the doctor for further evaluation and management to prevent complications like organ failure.

Choice B reason: A blood pressure of 125/68 mmHg is within normal to slightly elevated ranges, not immediately concerning. It does not warrant urgent reporting unless accompanied by symptoms or trends suggesting instability, as it aligns with typical adult values under most clinical guidelines.

Choice C reason: A blood pressure of 144/76 mmHg is elevated but not critical unless persistent or symptomatic. It suggests prehypertension or early hypertension, which may need monitoring but not immediate reporting unless other clinical factors, like symptoms or patient history, indicate urgency.

Choice D reason: A blood pressure of 150/70 mmHg is elevated, indicating possible hypertension, but not an emergency unless accompanied by symptoms like chest pain. It requires monitoring rather than immediate reporting, as it falls short of hypertensive crisis thresholds like 180/120 mmHg.

Choice A reason: Providing a blueprint for patient-centered care describes the nursing process (assessment, diagnosis, planning, implementation, evaluation), guiding systematic care delivery. This is integral, unlike prescribing medications, a physician’s role. Assuming this is not part risks misunderstanding the process, critical for structured, effective nursing care in complex patient scenarios.

Choice B reason: Holistic care enhancing outcomes is central to the nursing process, addressing physical, emotional, and social needs through its steps. This contrasts with prescribing, which is medical. Assuming this is not part misaligns with the process’s purpose, risking fragmented care and reduced effectiveness in patient-centered nursing practice.

Choice C reason: A problem-solving approach for complex clients defines the nursing process, using data to address multifaceted needs systematically. Unlike prescribing, it’s a nursing responsibility. Assuming this is not part undermines the process’s role, risking ineffective care planning and interventions critical for managing complex patient conditions in clinical settings.

Choice D reason: Developing medication prescriptions is a physician’s role, not part of the nursing process, which focuses on assessment, diagnosis, planning, implementation, and evaluation. Nurses administer or educate about medications but don’t prescribe. This distinction ensures role clarity, preventing scope-of-practice errors and supporting collaborative, patient-centered care in healthcare settings.