When Taking the Blood Pressure of a Very Ill Client,the

When taking the blood pressure of a very ill client,the nurse observes that the client's hand undergoes flexion contractions.Which intervention is most appropriate?

A) Administer isotonic intravenous fluids.
B) Remove the blood pressure cuff and give oxygen.
C) Ensure the client has a patent intravenous line.
D) Document the finding in the client's chart.