Which adult vital signs would the nurse need to report immediately?
1. 99.2 °F; 100; 20; 138/88
2. 100.2 °F; 88; 18; 128/72
3. 97.4 °F; 96; 28; 142/82
4. 98 °F; 64; 14; 88/60
Correct Answer: 3
The client with these vital signsâ€"97.4 °F; 96; 28; 142/82â€"has a rapid respiratory rate and a high normal heart rate, which could be secondary to respiratory distress and anxiety related to hypoxemia, so it should be reported to the health care provider immediately. The client with these vital signsâ€"98 °F; 64; 14; 88/60â€"needs further assessment of symptoms to determine if a problem exists, but vital signs are close to normal values, so the nurse would not be the most concerned with these measurements. The clients with these vital signsâ€"99.2 °F; 100; 20; 138/88 and 100.2 °F; 88; 18; 128/72â€"both have mild fevers. The nurse would need to report the temperature of 100.2 °F to the health care provider, but there is no urgency.
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