When sponging the client who has a high fever, the nurse observes the client shivering. What is the nurse's best first action?
A. Switch from tap water to saline.
B. Document the observation as the only action.
C. Stop sponging the client and retake his or her temperature.
D. Increase the temperature of the water and continue sponging.
C
Shivering is an indication that the client is being cooled too fast and can lead to an increase in body temperature. The nurse should stop the sponging and immediately assess the client's tem-perature.
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