A client has a prescription for vital sign measurement every four hours. The nurse observes that the client’s blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

Choice A reason: Obtaining an automatic blood pressure machine for hourly readings is not the immediate priority. While closer monitoring may be warranted, the nurse must first confirm the accuracy of the elevated reading before changing the frequency of assessments. Choice B reason: Waiting to reassess only if the client reports symptoms is unsafe. Hypertension can be asymptomatic, and delaying reassessment risks missing a critical change in condition. Choice C reason: Repeating the blood pressure measurement in fifteen minutes is the most appropriate action. This allows the nurse to confirm whether the elevated reading is persistent or due to a temporary factor such as pain, anxiety, or movement. Accurate reassessment ensures appropriate escalation of care if hypertension is sustained. Choice D reason: Planning to measure the blood pressure in four hours as prescribed ignores the significant change in the client’s condition. Delaying reassessment could allow hypertension to worsen, increasing the risk of complications such as stroke or cardiac events.