Question

A nurse in an emergency department is caring for a client who has a BP of 254/139. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

A. Administering an antihypertensive medication
B. Initiating continuous blood pressure monitoring
C. Assessing for signs of target organ damage
D. Notifying the healthcare provider immediately

Answer 1

The correct option is (A). Administering an antihypertensive medication. The nurse should first initiate continuous blood pressure monitoring as the client is in a hypertensive crisis. This allows for closer monitoring of the patient's blood pressure and the effectiveness of interventions.

Step-by-step explanation:

The nurse should first take the action of initiating continuous blood pressure monitoring. A hypertensive crisis is a medical emergency characterized by severely high blood pressure (such as the given reading of 254/139). Continuous monitoring allows the nurse to closely monitor any changes in the patient's blood pressure and helps in determining the effectiveness of any interventions.

Administering an antihypertensive medication can be a potential intervention, but it should not be the nurse's first action. Assessing for signs of target organ damage is important, but it can be done while continuously monitoring the blood pressure. Notifying the healthcare provider immediately is essential, but it should be done after initiating continuous blood pressure monitoring.