A nurse is caring for a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?

Clients with Chronic kidney disease often develop hypertension due to fluid overload, altered renin-angiotensin system activity, and impaired sodium excretion. Accurate blood pressure assessment is critical because treatment decisions depend on reliable readings. When an assistive personnel reports a critically high value, the nurse must first verify the measurement before initiating interventions or escalating care. This ensures patient safety and prevents unnecessary or inappropriate treatment. Rationale: A. Reporting the blood pressure reading to the charge nurse is not the first action because the accuracy of the reported value has not yet been confirmed. Escalation should occur only after verifying the data. Immediate communication without reassessment may lead to inappropriate clinical decisions based on an inaccurate reading. B. Remeasuring the client’s blood pressure is the priority action to confirm the validity of the reported value. Equipment error, improper cuff size, or incorrect technique by assistive personnel may produce falsely elevated readings. Verification ensures that subsequent interventions are based on accurate clinical data and supports safe nursing judgment. C. Instructing the client to remain in bed may be appropriate if hypertension is confirmed, but it does not address the priority need to verify the blood pressure reading first. Without confirmation, restricting activity may be unnecessary or unrelated to the client’s actual condition. Assessment must always precede intervention. D. Administering an antihypertensive medication is inappropriate without first confirming the blood pressure and obtaining a provider’s order. Antihypertensive drugs can cause rapid blood pressure reduction, leading to complications such as hypotension or decreased organ perfusion if given unnecessarily. Safe medication administration requires validated data and proper authorization.