一位高血壓病史的病人主訴突然劇烈頭痛及頭暈，護理師應採取的第一項行動為何？
A client with a history of hypertension reports a sudden onset of severe headache and dizziness. What is the nurse's first action?
- ACheck the client's blood pressure✓ 正解測量病患的血壓
- BAssist the client to stand up to check for orthostatic hypotension協助病患站立以檢查姿勢性低血壓
- CAdminister the scheduled antihypertensive medication給予預定之降血壓藥物
- DCall the physician immediately立即通知醫師
護理程序（Nursing Process）的第一步為評估（Assessment）。當病人出現高血壓病史並伴隨突發性劇烈頭痛與頭暈，需懷疑高血壓急症（Hypertensive Emergency）。在採取任何治療行動前，必須先取得客觀的生理數據（血壓），以評估病人的生命徵象是否處於危險範圍，並作為後續通報醫師的重要依據。
Before administering potassium chloride, the most critical assessment is verifying adequate urine output because potassium is primarily excreted by the kidneys. Administering potassium to a client with oliguria or anuria can rapidly lead to life-threatening hyperkalemia, resulting in cardiac arrhythmias or arrest. While IV patency and heart rhythm monitoring are important, confirming renal function via urine output is the essential prerequisite for safe administration.