A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?

A.Swollen tongue: Swelling of the tongue can indicate an allergic reaction, which could progress to a severe condition known as anaphylaxis. Immediate intervention is necessary.

B. Heart rate: While the heart rate is not directly mentioned in the notes, an increase in heart rate could be a physiological response to an allergic reaction or anaphylaxis. Monitoring heart rate is crucial in assessing the severity of the reaction.

C. Bilateral breath sounds with scattered wheezing upon auscultation: Wheezing indicates a potential respiratory issue, and when associated with itching, urticaria, and swelling, it suggests an allergic reaction or anaphylaxis. Prompt intervention is needed.

D. Blood pressure: Although blood pressure is important to monitor, it is not directly mentioned in the nurses' notes. However, if anaphylaxis or a severe allergic reaction is suspected, blood pressure can be affected, and it should be monitored.

E. Temperature: Fever is not mentioned in the notes, and the information provided suggests an immediate allergic reaction rather than an infectious process. Monitoring temperature is generally important but may not be a priority in this specific context.

F.Urticaria (hives): Hives are a sign of an allergic reaction and, when accompanied by other symptoms like swelling, require immediate attention.

A. Direct a fire extinguisher at the fire:

While using a fire extinguisher is an essential action in controlling a small fire, it should come after the fire alarm has been activated. Alerting others to the fire and initiating the emergency response system take precedence to ensure a coordinated and safe response.

B. Place wet towels along the base of the door:

Placing wet towels along the base of the door is a method to help prevent smoke from entering the room. However, in this situation, after ensuring the client's safety, the nurse should focus on activating the facility's fire alarm to alert others and initiate the emergency response.

C. Turn off any electrical equipment:

While turning off electrical equipment is a generally sound practice in fire safety, it is not the immediate next action after moving the client to safety. Activating the fire alarm takes precedence as it initiates a coordinated response and alerts others to the emergency.

D. Activate the facility's fire alarm:

This is the correct action. Activating the fire alarm is a critical step in alerting the entire facility to the presence of a fire. It ensures that emergency response teams are notified promptly, and appropriate measures can be taken to address the fire, including evacuating other occupants and summoning professional firefighting assistance.