Vital signs for a patient reveal a high blood pressure of 187/100 . Orders state to notify the health care provider for diastolic blood pressure greater than 90 . What is the nurse's first action?
a. Assess the patient for other symptoms or problems, and then notify the health care provider.
b. Review the most recent lab results for the patient's potassium level.
c. Follow the clinical protocol for a stroke.
d. Administer an antihypertensive medication from the stock supply, and then notify the health care provider.
A
The best answer is to briefly reassess the patient for other symptoms or problems, and then notify the health care provider according to the orders. Reviewing the potassium level does not address the problem of high blood pressure. The nurse does not make medical diagnoses, such as stroke. The nurse needs an order to administer medications.
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