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?

A) Recheck the client's blood pressure personally.

B) Instruct the LPN to administer an antihypertensive medication.

C) Inform the surgeon about the elevated blood pressure.

D) Document the findings in the client's chart and continue with other tasks.

Answer 1

The RN should first recheck the client's blood pressure to confirm the reading before considering further actions.

Step-by-step explanation:

When an LPN reports a blood pressure that is significantly higher than the client's previous reading after a cholecystectomy, the RN's first action should be to recheck the client's blood pressure personally. This step is crucial to confirm the accuracy of the reading before taking further action. If the RN verifies that the blood pressure is indeed elevated, they can then consider additional steps like informing the surgeon or administering medications under the correct protocol and after a physician's order. Immediate documentation and continuing other tasks may not appropriately address a potentially urgent clinical change. Hence, the RN should prioritize validating the blood pressure measurement to ensure patient safety and the correct management of care.