A nurse reviews vital signs for a patient admitted last night with an injury sustained while intoxicated
The medical record shows these blood pressure and pulse readings: Admission, 2 AM - 118/78 mm Hg and 72 beats/min 4 AM - 126/80 mm Hg and 76 beats/min 6 AM - 128/82 mm Hg and 72 beats/min 8 AM - 132/88 mm Hg and 80 beats/min 10 AM - 148/94 mm Hg and 96 beats/min What is the nurse's priority action? a. Force fluids.
b. Consult the health care provider.
c. Obtain a clean-catch urine sample.
d. Place the patient in a vest-type restraint.
B
Elevated pulse and blood pressure may indicate impending withdrawal delirium and that additional sedation is warranted. None of the other options takes into account the possible need for sedation. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.
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