The nurse is taking vital signs for a client with a history of hypertension. The client's blood pressure is 180/100 mmHg, heart rate 88 beats/min, and respirations 16 breaths/min. The client denies any symptoms. What should the nurse do next?

Question: The nurse is taking vital signs for a client with a history of hypertension. The client's blood pressure is 180/100 mmHg, heart rate 88 beats/min, and respirations 16 breaths/min. The client denies any symptoms. What should the nurse do next?

Answer options:

• Administer a PRN dose of antihypertensive medication. ✅ Recheck the blood pressure on the other arm after a few minutes.
• Notify the healthcare provider immediately due to hypertensive crisis.
• Document the finding and continue routine monitoring.

Correct answer: Recheck the blood pressure on the other arm after a few minutes.

Explanation: Before initiating any intervention for an elevated blood pressure reading (especially if asymptomatic), it is crucial to confirm the reading. Rechecking the blood pressure in the other arm after a few minutes can rule out a false reading and provide a more accurate assessment.