Question

An adult patient who arrived at the triage desk in the emergency department (ED) with minor facial lacerations after a motor vehicle accident has a blood pressure (BP) of 182/94. Which action by the nurse is appropriate?

a. Start an IV line to administer antihypertensive medications.
b. Recheck the blood pressure after the patient has been assessed.
c. Discuss the need for hospital admission to control blood pressure.
d. Teach the patient about the stroke risk associated with uncontrolled hypertension.

Answer 1

The appropriate action for the nurse is to recheck the patient's blood pressure after conducting a full assessment.

Step-by-step explanation:

The appropriate action for the nurse to take when an adult patient arrives at the triage desk in the emergency department with minor facial lacerations and a blood pressure of 182/94 is to b. Recheck the blood pressure after the patient has been assessed.

Starting an IV line to administer antihypertensive medications (option a) would not be appropriate since the patient's blood pressure reading is only a single measurement and may be elevated due to the stress of the accident. Further assessment is needed before determining the need for hospital admission to control blood pressure (option c). Teaching the patient about the stroke risk associated with uncontrolled hypertension (option d) may be done later, but the priority is to reassess the patient's blood pressure after conducting a full assessment.