The nurse is preparing to administer a client's scheduled antihypertensive medication (lisinopril). The client's vital signs are: Blood pressure: 88/56 mmHg Heart rate: 62 bpm Respiratory rate: 18/min Oxygen saturation: 98% n room air

A. Encourage the client to drink fluids and then give the medication: While increasing fluid intake can help raise blood pressure if the cause is dehydration, it does not justify giving an antihypertensive to a hypotensive patient. Administering lisinopril will further lower the pressure regardless of fluid status. The priority is to avoid exacerbating the existing hypotension. B. Hold the dose and notify the healthcare provider: A blood pressure of 88/56 is significantly below the normal therapeutic range and indicates that the patient cannot tolerate further antihypertensive therapy. Giving the lisinopril could lead to profound hypotension, syncope, or decreased organ perfusion. The nurse must withhold the drug and seek medical guidance for dose adjustment. C. Give half the dose and recheck the blood pressure in 30 minutes: Nurses are not authorized to alter the prescribed dose of a medication or provide a partial dose without a specific physician order. Even a half-dose of an ACE inhibitor could be dangerous for a client whose pressure is already below 90 mmHg systolic. Clinical judgment requires stopping the medication entirely until the patient is stable. D. Document the finding and give the drug as usual: Giving the drug as usual despite a blood pressure of 88/56 is a medication error that ignores critical assessment data. This action directly endangers the patient and violates basic safety protocols for administering cardiovascular medications. Documentation of the vital signs must be followed by an appropriate clinical action, which is withholding the dose.