Difficulty: Medium
Average Score: 75%
Simulated
The nurse is caring for a patient with the following vital signs: Temperature: 98.9┬░ F, Pulse: 94, Respirations: 20, Blood pressure: 144/94, Pulse oximetry: 94%. What is the priority action of the nurse?
Correct answer
D
Rationale
The correct answer is D: Ask the patient about his usual blood pressure results. This is the priority action because the patient's blood pressure reading of 144/94 is elevated, indicating hypertension. By asking the patient about his usual blood pressure results, the nurse can determine if this reading is normal for the patient or if it is a new development that requires further assessment or intervention. This proactive approach helps in identifying any potential issues early on and ensures appropriate care is provided.
Other choices are incorrect:
A: Documenting the findings is important, but addressing the elevated blood pressure takes precedence.
B: Applying a cool washcloth may help with fever management but does not address the elevated blood pressure.
C: Administering oxygen may be needed for hypoxia indicated by the low pulse oximetry, but the priority is addressing the elevated blood pressure.
Overall, understanding the significance of the vital signs and prioritizing the assessment and management of the elevated blood pressure is crucial in this scenario.
Other choices are incorrect:
A: Documenting the findings is important, but addressing the elevated blood pressure takes precedence.
B: Applying a cool washcloth may help with fever management but does not address the elevated blood pressure.
C: Administering oxygen may be needed for hypoxia indicated by the low pulse oximetry, but the priority is addressing the elevated blood pressure.
Overall, understanding the significance of the vital signs and prioritizing the assessment and management of the elevated blood pressure is crucial in this scenario.