At last measurement, the client's vital signs were as follows:
oral temperature 98°F (36.7°C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature 103.2°F (38.5°C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should the nurse's first intervention be at this time?
a. Ask the client whether he has had a warm drink in the last 30 minutes.
b. Notify the primary care provider of the client's temperature.
c. Ask the client whether he is feeling chilled.
d. Take the temperature by a different route.
A
With a fever, the heart rate and respiratory rate are usually elevated. In this case, they are within normal limits, so the nurse should wonder about the accuracy of the temperature reading and validate it in some way. Because having a hot drink is a common cause of false readings, the nurse should determine whether that has occurred before retaking or otherwise validating the reading.
You might also like to view...
A patient with liver impairment needs an antiepileptic drug. What drug would be safest for patients with liver impairment?
A) Levetiracetam (Keppra) B) Lamotrigine (Lamictal) C) Phenobarbital D) Valproic acid (Depakene)
After teaching a group of students about participatory action research, the instructor determines that the students need additional teaching when they state which of the following as a main component?
A) Problem inquiry B) Participant organization C) Awareness and action D) Issue identification
Group ____________________ is/are best defined as underlying forces that produce behavior patterns within the group
Fill in the blank(s) with correct word
In the United States, the system of health care has historically given and continues to give stronger support to what type of care? 1. Individual rather than community care 2. Community rather than individual care
3. Cure rather than prevention 4. Preventions rather than cure A) 1, 3 B) 1, 4 C) 2, 3 D) 2, 4