A nurse is caring for a client hospitalized with botulism. The nurse obtains the following vital signs: temperature—99.8° F (37.6° C), pulse—100, respiratory rate—10 and shallow, and blood pressure—100/62 mm Hg
What action by the nurse is most appropriate? a. Allow the client rest periods without in-terruption.
b. Stay with the client while another nurse calls the physician.
c. Check the client's IV rate and document all findings.
d. Help the client order appropriate food items from the menu.
B
A client with botulism is at risk for respiratory failure. This client's respiratory rate is slow and shallow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. Nothing is allowed by mouth until all respiratory function and swallowing are normal. The nurse should monitor and document the IV infusion per protocol, but this does not take priority. Allowing the client to rest and ordering food items are not appropriate actions.
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