After measuring the client’s vital signs, the nurse obtains the follow

After measuring the client’s vital signs, the nurse obtains the following results: blood pressure = 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5° C. The nurse should:

1. Retake the blood pressure
2. Retake the client’s temperature
3. Report all of the findings immediately
4. Record the findings as within normal limits

ANSWER

ANS: 1
The normal blood pressure reading is 120/80 mm Hg. This client’s blood pressure is significantly higher at 180/100 mm Hg, and may be an indication of hypertension. (One elevated blood pres-sure measurement does not qualify as a diagnosis of hypertension; it would have to be elevated on at least two separate occasions). The nurse should retake the blood pressure. The client’s tem-perature is within normal limits for a rectal temperature. The average rectal temperature is 37.5° C. The nurse should repeat the blood pressure measurement to confirm the reading before report-ing the findings. The blood pressure reading is not within normal limits. The pulse rate, respirato-ry rate, and temperature are within normal limits.