Difficulty: Medium
Average Score: 88%
Full-length
While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse's initial action should be to:
Correct answer
B
Rationale
Rechecking vital signs ensures accuracy, as the low diastolic BP may be an error, and guides further action.