The unlicensed assistive personnel reports a client blood pressure of 90/60 mm Hg to the nurse. The client's prescriptions say to notify the health care provider (HCP) if systolic blood pressure is

Question

The unlicensed assistive personnel reports a client blood pressure of 90/60 mm Hg to the nurse. The client's prescriptions say to notify the health care provider (HCP) if systolic blood pressure is <100 mm Hg. What should the nurse do first?

Quizplus · Accepted Answer

The nurse should follow the client's prescriptions and notify the HCP, after first assessing for any other signs and symptoms that may be associated with the low blood pressure (eg, dizziness, pallor, signs of poor perfusion, confusion). The HCP will most likely ask the nurse about the type of symptoms as well as past vital signs, medications, and laboratory results. The nurse should utilize SBAR, a common tool for communication with HCPs that includes Situation, Background, Assessment, and Recommendation. The nurse should have all of this information on hand prior to calling the HCP. SBAR (Options B, C, and D) These options are appropriate after the nurse has assessed the client. Educational objective: The nurse should have current assessment data and access to the client's recent laboratory data, diagnostic studies, and medication administration record before calling the HCP.

The Unlicensed Assistive Personnel Reports a Client Blood Pressure of 90/60