The nurse is providing care for a client. The client’s blood pressure was 120/82 approximately 30 minutes ago. The current blood pressure is 88/50. What action by the nurse is the most appropriate?

Choice A reason: Repeating the blood pressure in 30 minutes is unsafe because the client’s blood pressure has dropped significantly in a short period. Waiting could delay life-saving interventions. Immediate action is required to address potential shock or cardiovascular collapse. Choice B reason: Documenting and continuing to monitor is inappropriate because the client is showing signs of acute hypotension. Passive monitoring without intervention places the client at risk for deterioration. Documentation is important but must accompany urgent action. Choice C reason: Reassuring the client that they are doing well is misleading and unsafe. The client’s blood pressure indicates a critical condition that requires immediate intervention. False reassurance could delay recognition of the seriousness of the situation. Choice D reason: Calling the Rapid Response team is the most appropriate action. A sudden drop in blood pressure from 120/82 to 88/50 suggests possible shock, internal bleeding, or sepsis. Rapid Response teams are trained to provide immediate advanced interventions, stabilize the client, and prevent cardiac arrest. This action prioritizes patient safety and aligns with emergency protocols.