Difficulty: Medium
Average Score: 89%
Simulated
Before ambulating the client for the first time, the nurse obtains the client's BP with an automatic BP machine. Which actions should the nurse take first when obtaining a BP reading of 86/56 mm Hg and pulse rate of 64 bpm?
Correct answer
A
Rationale
A: Assessing for hypotension symptoms like dizziness or cold extremities is priority. B: Retaking BP follows assessment. C: Ambulating risks falls with hypotension. D: Reviewing records is secondary.