Question

An RN delegates the task of obtaining the blood pressure of a client who is 2 hr postoperative following a cholecystectomy to a licensed practical nurse (LPN). The LPN reports a blood pressure that is significantly higher than the client's previous reading. Which of the following actions should the RN take first?

Option 1: Recheck the client's blood pressure.

Option 2: Treat the client's blood pressure with a prescribed antihypertensive.

Option 3: Ask the LPN to review the technique for obtaining blood pressure.

Option 4: Review the client's medical record for other episodes of elevated blood pressure.

Answer 1

The RN should first recheck the client's blood pressure to ensure accuracy and address potential measurement errors. If the rechecked blood pressure is still high, the RN should review the client's medical record for other instances of elevated blood pressure. Only after confirming accuracy and ruling out existing conditions should other interventions be considered.

Step-by-step explanation:

The RN should first recheck the client's blood pressure (Option 1). This is important to ensure the accuracy of the initial reading and address any potential measurement errors. The RN should use a proper technique and appropriate equipment to obtain an accurate blood pressure measurement.

If the rechecked blood pressure still indicates a significant increase, the RN should then review the client's medical record for other episodes of elevated blood pressure (Option 4). This step will help determine if the client has a history of hypertension or if the elevated blood pressure is a new finding.

Only after confirming the accuracy of the blood pressure measurement and ruling out any existing medical conditions should the RN consider other interventions such as treating the elevated blood pressure with a prescribed antihypertensive (Option 2) or asking the LPN to review the technique for obtaining blood pressure (Option 3).