An LPN in an outpatient endocrine clinic checks a 76-year-old man with type 2 diabetes mellitus who was just fitted with new hearing aids. He reports feeling lightheaded. Vital signs are BP 96/60 mmHg, HR 122/min, RR 20/min, temp 98.2°F (36.8°C), and point-of-care glucose 118 mg/dL. Ten minutes ago his BP was 128/74 mmHg and HR was 80/min. Which action should the nurse take first?
- Proceed with the scheduled hearing aid fitting follow-up since glucose is normal
- Report the vital sign changes to the RN or health care provider now
- Document the new blood pressure and heart rate in the chart and continue the visit without notifying the RN or health care provider
- Wait until the next scheduled recheck in one hour to see if vitals improve