A 42-year-old client has a rectal temperature reading of 39.2°C (102.6°F). Her blood pressure has decreased from 124/76 to 118/70 since taken 4 hours earlier. Her pulse rate has increased from 68 to 78 . The nurse's initial best action is to:
a. Document the vital signs and continue with her assessment
b. Contact the provider immediately due to the alarming changes in the vital signs
c. Obtain a pulmonary artery temperature reading before initiating any type of treatment
d. Ask the NAP to obtain another set of vital signs in 4 hours
D
The nurse simply needs to continue monitoring the patient's vital signs. The patient's temperature of 102.5°F (39.2°C) is not considered an emergency temperature for an adult. A moderate fever of up to 103°F (39.4°C) is considered a mechanism by which the body fights off infection. The metabolic rate is expected to increase with a fever, which will lead to an increase in the pulse rate. Blood pressure is more likely to decrease with a fever because of peripheral vasodilation.
You might also like to view...
A nurse takes a dinner tray to a patient who has been pacing and preoccupied. The patient suddenly places his butter knife against his throat and demands that everyone stay back
Which of the following considerations should be kept in mind in responding to this situation? Select all that apply. a. Maintaining and conveying a sense of calm confidence helps calm the patient. b. The patient will require restraint because he has presented a danger to self. c. In that the patient is not in control, the nurse should control what happens. d. Determine what the patient considers to be his need, to be important to him. e. Ask the patient for ideas about what he thinks would help resolve the crisis. f. Tell the patient that your goal is that everyone remains safe while you talk.
An implementation that can be used to help prevent relapse in a patient who has a substance abuse problem is:
1. self-hypnosis. 2. imagery. 3. stress management. 4. blocking.
The nurse reminds the nursing assistant that the purpose of locking the wheels of a wheelchair is to:
a. supply a stable support for a patient to lift self. b. keep patient in a position at a table or bedside. c. prevent falls. d. keep the patient from moving self.
The proper procedure to be used when removing a dressing that is sticking to a wound is by
A. placing a heating pad on the wound to loosen the scab. B. softening the dressing with normal saline. C. gently pulling the dressing off from front to back. D. spraying the dressing with an anesthetic to reduce patient discomfort.