Basic Care and Comfort NCLEX PN Questions Nursing Practice Question
Before ambulating the client for the first time, the nurse obtains the client's BP with an automatic BP machine. Which actions should the nurse take first when obtaining a BP reading of 86/56 mm Hg and pulse rate of 64 bpm?
Correct Answer: A
Rationale: Assessing the client for dizziness and checking the temperature of extremities are crucial first steps after obtaining a low blood pressure reading. This ensures the nurse can evaluate the client's immediate condition and risk of falls or other complications.
Option B, retaking the BP with a manual cuff, may be necessary later but does not address the immediate safety concerns.
Option C, elevating the head of the bed and assisting the client out of bed, could lead to injury if the client is experiencing hypotension.
Option D, reviewing the medical record for normal BP range, is important but does not provide immediate assessment of the client's current state.