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?

A. Plan to measure the blood pressure in four hours as prescribed. Waiting for another four hours may not be appropriate given the significant increase in blood pressure. Immediate action is needed to address the elevated reading.B. Repeat the client’s blood pressure measurement in fifteen minutes. This is the most appropriate action. When a client’s blood pressure is significantly elevated, it’s essential to recheck it promptly to confirm accuracy and assess for any changes. Fifteen minutes allows enough time for a follow-up measurement without unnecessary delay.C. Obtain an automatic blood pressure machine for hourly readings. While continuous monitoring is valuable in some situations, it’s not necessary for routine blood pressure assessments. Hourly readings would be excessive and may not provide additional useful information.D. Reassess the blood pressure if the client reports other symptoms. While assessing other symptoms is essential, waiting for symptoms to occur before reassessing blood pressure is not the best approach. Immediate follow-up is warranted based on the elevated reading alone