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. Follow the clinical protocol for a stroke.
b. Review the most recent lab results for the patient's potassium level.
c. Assess the patient for other symptoms or problems, and then notify the health care provider.
d. Administer an antihypertensive medication from the stock supply, and then notify the health care provider.
ANS: C
Communication to other health care professionals must be timely, accurate, and relevant to a patient's clinical situation. The best answer is to 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 follow the protocol since the order says to notify the health care provider. The orders read to notify the health care provider, not administer medications.
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