A nurse is assisting in caring for a client who was just admitted with partial-thickness burns to their upper torso. Which of the following actions should the nurse take first?

Clients with Chronic kidney disease often develop hypertension due to fluid overload, altered renin-angiotensin system activity, and impaired sodium excretion. Accurate blood pressure assessment is critical because treatment decisions depend on reliable readings. When an assistive personnel reports a critically high value, the nurse must first verify the measurement before initiating interventions or escalating care. This ensures patient safety and prevents unnecessary or inappropriate treatment.

Rationale:
A. Reporting the blood pressure reading to the charge nurse is not the first action because the accuracy of the reported value has not yet been confirmed. Escalation should occur only after verifying the data. Immediate communication without reassessment may lead to inappropriate clinical decisions based on an inaccurate reading.

B. Remeasuring the client’s blood pressure is the priority action to confirm the validity of the reported value. Equipment error, improper cuff size, or incorrect technique by assistive personnel may produce falsely elevated readings. Verification ensures that subsequent interventions are based on accurate clinical data and supports safe nursing judgment.

C. Instructing the client to remain in bed may be appropriate if hypertension is confirmed, but it does not address the priority need to verify the blood pressure reading first. Without confirmation, restricting activity may be unnecessary or unrelated to the client’s actual condition. Assessment must always precede intervention.

D. Administering an antihypertensive medication is inappropriate without first confirming the blood pressure and obtaining a provider’s order. Antihypertensive drugs can cause rapid blood pressure reduction, leading to complications such as hypotension or decreased organ perfusion if given unnecessarily. Safe medication administration requires validated data and proper authorization.

Bronchitis involves inflammation of the bronchial tubes, often leading to airway narrowing, mucus production, and breathing difficulty. Medications such as bronchodilators are commonly prescribed to relieve bronchospasm and improve airflow. Albuterol is a short-acting beta2 agonist used to rapidly relax airway smooth muscles. Patient education focuses on its mechanism of action, proper use, and expected effects.

Rationale:
A. “You can expect to be drowsy after taking this medication.” Albuterol typically causes stimulation of the sympathetic nervous system rather than sedation. Common effects include nervousness, tremors, and tachycardia. Drowsiness is not an expected or therapeutic effect of this medication.

B. “The medication will help open up your airways so you can breathe easier.” This correctly describes the action of albuterol. It stimulates beta2-adrenergic receptors in bronchial smooth muscle, leading to bronchodilation. This reduces airway resistance and improves airflow, making breathing easier for clients with bronchitis or other obstructive airway conditions.

C. “The medication will help thin the mucus your airways produce.” Albuterol does not act as a mucolytic. It does not change the consistency of secretions but instead relaxes bronchial smooth muscle. Medications like expectorants or hydration are used to assist mucus clearance.

D. “You must wait 10 seconds between each inhalation.” Proper inhaler technique generally requires waiting about 1 minute between puffs to allow adequate drug deposition and absorption. The statement does not reflect correct inhalation spacing guidelines and may indicate misunderstanding of proper inhaler use.