The blood pressure and pulse rates for a client admitted last night with a compound fracture of the

Question

femur sustained in a fall while intoxicated, are recorded as follows:
admission 2 AM, 122/80 mm Hg and 72 beats/min
4 AM, 126/78 mm Hg and 76

beats/min
6 AM, 124/80 mm Hg and 72 beats/min
8 AM, 132/88 mm Hg and 80 beats/min
10 AM, 148/88 mm Hg and 96 beats/min
The priority action for the nurse to take is to
a. encourage the client to drink plenty of liquids.
b. obtain a clean-catch urine sample.
c. place the client in a vest-type restraint.
d. notify the physician.

Answer 1

D
Elevated pulse and blood pressure may indicate that the client is going into withdrawal delirium and
that additional sedation is warranted. None of the other options takes into account the possible need
for sedation. Options B and C: No indication is present that the client may have a urinary tract
infection or is presently in need of restraint. Option A is too nonspecific. Overhydration may bring
on its own set of problems.