A patient’s blood pressure readings over three checks rise from 128/76 mmHg to 146/84 mmHg and then to 164/92 mmHg over four hours. Which nursing action is most appropriate?
Correct answer: B. Repeat the measurement and assess for related symptoms
- A. Ignore the readings because the patient has no symptoms
- B. Repeat the measurement and assess for related symptoms
- C. Give an antihypertensive dose without a prescription
- D. Ask the patient to exercise before the next reading
Explanation
A progressive rise is a clinically important trend even when the patient feels well. The nurse should verify the measurement with correct cuff size and technique, assess for symptoms such as headache, chest pain, or neurological changes, and report persistent or severe elevation according to policy.
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About Vital Signs and Monitoring
Vital signs include temperature, pulse, respiration, blood pressure, oxygen saturation and pain assessment. Coverage includes correct measurement sites and techniques, normal adult ranges, factors that alter readings, trends in patient observations, and the difference between an abnormal finding that needs reassessment and one requiring immediate reporting.
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