Difficulty: Medium
Average Score: 74%
Simulated
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
Correct answer
D
Rationale
Measuring BP in the other arm verifies the reading, as a sudden increase may indicate an issue or error.