A 36-year-old African-American patient has been admitted to the hospital with diabetic ketoacidosis. The nurse who is admitting him notes that his blood pressure is 164/98 . Which of the following should the nurse do next?
a. Call the health care provider because the patient's values differ from the standard range.
b. Immediately call the health care provider and request antihypertensive medication.
c. Ask the patient what his blood pressure normally measures for comparison.
d. Do nothing; this is within a normal range for a patient with diabetic ketoacidosis.
C
Know the patient's usual range of vital signs. A patient's usual values sometimes differ from the standard range for that age or physical state. Use the patient's usual values as a baseline for comparison with findings taken later. A single measurement does not adequately reflect a patient's blood pressure. Blood pressure trends, not individual measurements, guide your nursing interventions. Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg
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