A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
A) Oral temperature of 100°F
B) Tachypnea and restlessness
C) Frequent loose stools
D) Weight loss of 1 pound since yesterday
Ans: B
Feedback:
In prioritizing care, the pneumonia would be assessed first by the nurse. Tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 pound is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 100°F is not considered a fever and would not be the first issue addressed.
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