Kenny Barrett, 64 years old, was admitted for observation of initial administering of BP his treatment with blood pressure of 220/124 after visiting his doctor for a routine physical. ECG was unremarkable. No past history of HTN. Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. IV with NS @ 125 mL/ hr. Patient has been complaining of a headache and dizziness. He is a patient of Dr. Adams. You responded correctly to 4 out of 6 evaluations: Category Your response Explanation Perfusion (yes) Incorrect acuity Patient is at risk because of his BP and pulse Gas exchange (no) Incorrect acuity No indication at this time Interpersonal violence (no) Incorrect acuity No indication at this time Addiction (yes) Incorrect acuity History of 1 pack a day smoker for the past 20 years Cognition (no) Incorrect acuity Patient is AAO x 4 Sexuality (no) Incorrect acuity No evidence of abnormal sexual history Scenario 1 When reviewing your patients’ vital signs, taken by the UAP, you notice Kenny has a blood pressure of 190/110 and a pulse of 105. What actions by the nurse are appropriate?
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