A nurse receives a report from an assistive personnel that a client's blood pressure is 160/95 mm Hg. Which of the following actions should the nurse take first?

Report the finding to the provider.

Compare the finding to the client's blood pressure baseline.

Administer antihypertensive medications as prescribed.

Recheck the client's blood pressure.

Answer and Explanation

The Correct Answer is D

A. Report the finding to the provider. While the provider should be informed if the hypertension is new, persistent, or symptomatic, the nurse should first verify the blood pressure before escalating the concern.

B. Compare the finding to the client's blood pressure baseline. Checking the baseline is important, but the first action should be to confirm the accuracy of the reading by rechecking it. If the reading is consistent with previous values, the nurse can then compare it to the baseline.

C. Administer antihypertensive medications as prescribed. Administering medication without confirming the blood pressure reading could lead to unnecessary treatment or hypotension if the reading was inaccurate. The nurse should first recheck the BP.

D. Recheck the client's blood pressure. Rechecking the blood pressure ensures accuracy before making clinical decisions. Factors such as incorrect cuff size, client positioning, or transient increases (e.g., anxiety or pain) could cause an elevated reading. If the elevated BP is confirmed, then further action (e.g., notifying the provider or administering medication) can be taken.

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Correct Answer is C

Explanation

A. Administer antibiotic therapy to the client. This is a priority intervention, but it is not the first action. Before administration, infection control measures should be in place.

B. Provide the client with analgesics as needed. Pain management is important but is not the first priority. The spread of infection must be controlled immediately.

C. Initiate droplet precautions for the client. Meningococcal meningitis is highly contagious. Droplet precautions (mask, private room) must be initiated immediately to prevent transmission before other interventions.

D. Educate the client about the meningococcal vaccine. Vaccination is a preventive measure but does not address the immediate risk of infection spread.

A. Ask the client to describe their feelings. B. Discuss the competency of the surgeon with the client. C. Inform the client that others have had the procedure without problems. D. Ask the client why they are experiencing anxiety.

Correct Answer is A

Explanation

A. Ask the client to describe their feelings. Encouraging the client to express their emotions allows the nurse to assess their concerns and provide appropriate support. This is a key principle of therapeutic communication.

B. Discuss the competency of the surgeon with the client. While the surgeon's competency may help reassure the client, the nurse should not comment on the surgeon’s skill. Instead, the nurse should focus on the client's emotions and provide factual information about the procedure if needed.

C. Inform the client that others have had the procedure without problems. This response dismisses the client’s concerns rather than addressing their feelings. Each client’s experience is unique, and reassurance should be based on listening and providing accurate information.

D. Ask the client why they are experiencing anxiety. Asking “why” can make the client feel defensive. Instead, the nurse should use open-ended questions, such as "Can you tell me more about your concerns?", which encourages discussion without judgment.

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