The nurse obtains the following results after measuring the client's vital signs: Blood pressure, 180/100; pulse, 82 beats per minute; respiratory rate, 16 breaths per minute; and rectal tempera-ture, 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
A normal blood pressure reading is 120/80 or less. This client's blood pressure is significantly higher at 180/100 and may be an indication of hypertension. (One elevated blood pressure meas-urement 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.
The client's temperature is within normal limits for a rectal temperature. The average rectal temperature is 37.5ºC.
The nurse should retake the blood pressure to confirm the reading before reporting the findings.
The blood pressure reading is not within normal limits. The pulse, respiratory rate, and tempera-ture are within normal limits.
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