A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed:
0200: 118/78 mm Hg and 72 beats/min
0400: 126/80 mm Hg and 76 beats/min
0600: 128/82 mm Hg and 72 beats/min
0800: 132/88 mm Hg and 80 beats/min
1000: 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.
ANS: B
Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. 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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