Difficulty: Medium
Average Score: 82%
Simulated
Passage / Scenario
A nurse and assistive personnel are assigned a group of clients on the unit.Which of the following clients should the nurse instruct the AP to report to the nurse?
Correct answer
D
Rationale
The correct answer is D. A blood pressure of 88/52 mmHg is considered hypotensive and requires immediate attention. The nurse should instruct the AP to report this vital sign reading to the nurse for further assessment and intervention to prevent complications such as hypoperfusion to vital organs. Choices A, B, and C do not pose immediate life-threatening risks and can be addressed during routine care. Choice D stands out as the priority due to the potential for serious consequences if not addressed promptly.