The nurse obtains the following results after measuring the patient's vital signs: blood pressure 180/100 mm Hg, pulse 82 beats per minute, respiratory rate 16 breaths per minute, and rectal temperature 37.5°C
Which of the following actions should the nurse take? a. Retake the blood pressure.
b. Retake the temperature.
c. Report all of the findings immediately.
d. Record the findings as within normal limits.
A
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A A normal blood pressure reading is considered to be 139/89 mm Hg or lower. This patient's blood pressure reading is significantly higher at 180/100 mm Hg and may be an indication of hypertension. (One elevated blood pressure measurement does not qualify as a diagnosis of hypertension; it would have to be elevated on at least two separate occasions.) The nurse should retake the blood pressure.
B The patient's temperature is within normal limits for a rectal temperature. The average rectal temperature is 37.5ºC.
C The nurse should retake the blood pressure to confirm the reading before reporting the findings.
D The blood pressure reading is not within normal limits. The pulse, respiratory rate, and temperature are within normal limits.
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