Difficulty: Medium
Average Score: 95%
Practice
A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?
Correct answer
C
Rationale
The correct first action for the nurse in this scenario is to recheck the blood pressure. This step is crucial to confirm the accuracy of the initial reading. Administering antihypertensive medication without verifying the blood pressure could lead to inappropriate treatment. Notifying the healthcare provider can be done after ensuring the accuracy of the reading. Simply documenting the blood pressure without validation may result in acting on potentially incorrect information. Therefore, the priority is to recheck the blood pressure.