Recommendation: Immediate intervention for hypertensive crisis. Consider adjusting or administering

The nurse is caring for a client who is 1 day postoperative, has an intravenous (IV) infusion of 0.9% sodium chloride (normal saline), an indwelling urethral catheter with hourly output measurements, and the assessment findings indicated in the table below. 0800 1000 T 99.2° F 99.0° F P 90, regular 120, irregular R 18 20 BP 122/76 mm Hg 106/58 mm Hg SaOâ‚‚ 98% 95% Urine output 60 mL 40 mL Skin Warm, dry Cool, clammy Potassium Not available 5.2 mEq/L Which of the following actions should the nurse take next? Start IV regular insulin by continuous infusion Assess the client’s capillary blood glucose level Obtain a blood specimen for type and cross match Assess the client’s level of consciousness (LOC) and orientation.

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