Difficulty: Medium
Average Score: 92%
Simulated
A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hr earlier. Which of the following changes should the nurse identify as the priority finding?
Correct answer
C
Rationale
A blood pressure drop to 86/50 mm Hg indicates hypotension, which can compromise tissue perfusion and lead to organ failure, making it the priority finding requiring immediate intervention.