Difficulty: Medium
Average Score: 83%
Simulated
A nurse just received a client from the emergency department, who presents to the floor with a history of stroke. He is admitted with left-sided weakness. His vital signs are to be monitored every 4 hours. On initial assessment at 0800 the client's blood pressure was noted to be 150/100. What priority action should the nurse do next?
Correct answer
C
Rationale
The correct answer is C: Repeat the blood pressure. The nurse should repeat the blood pressure to confirm accuracy and assess for any immediate need for intervention, especially given the client's history of stroke and elevated blood pressure. This action ensures that appropriate interventions can be initiated promptly if necessary.
A: Checking the patient's pulse and temperature is important but not the priority in this situation.
B: Having the UAP repeat the blood pressure is not appropriate as it is the nurse's responsibility to assess and monitor vital signs.
D: Administering the patient's morning medications should not be done without confirming the accuracy of the blood pressure reading first.
In summary, repeating the blood pressure is crucial for accurate assessment and timely intervention, making it the most appropriate next step in this scenario.
A: Checking the patient's pulse and temperature is important but not the priority in this situation.
B: Having the UAP repeat the blood pressure is not appropriate as it is the nurse's responsibility to assess and monitor vital signs.
D: Administering the patient's morning medications should not be done without confirming the accuracy of the blood pressure reading first.
In summary, repeating the blood pressure is crucial for accurate assessment and timely intervention, making it the most appropriate next step in this scenario.