At last measurement, the client's vital signs were as follows: oral temperature 98°F (36.7°C), heart rate 76, respiratory rate 16, and blood pressure (BP) 118/60. Four hours later, the vital signs are as follows:
oral temperature 103.2°F (38.5°C), heart rate 76 beats/minute, respiratory rate 14 breaths/minute, and blood pressure 120/66. Which should the nurse's first intervention be at this time?
1) Ask the client if he has had a warm drink in the last 30 minutes.
2) Notify the primary care provider of the client's temperature.
3) Ask the client if he is feeling chilled.
4) Take the temperature by a different route.
ANS: 1
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