A Nurse Reviews Vital Signs for a Patient Admitted with an Injury

Multiple Choice

A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/minute
0400: 126/80 mm Hg and 76 beats/minute
0600: 128/82 mm Hg and 72 beats/minute
0800: 132/88 mm Hg and 80 beats/minute
1000: 148/94 mm Hg and 96 beats/minute
What is the nurse's priority action?

A) Force fluids.
B) Begin the detox protocol.
C) Obtain a clean-catch urine sample.
D) Place the patient in a vest-type restraint.