The nurse assesses the client and finds that the client's temperature is 102°F. The nurse administers Tylenol 650 mg, as ordered by the physician, and repeats the temperature measurement in one hour for what purpose?
1. Assessment of the temperature
2. Diagnosing that the client still has a fever
3. Evaluating the effectiveness of the medication
4. Planning to take the temperature in one hour
3
Rationale 1: Retaking the temperature after administering the Tylenol is reassessing or evaluating the effectiveness of the treatment. While taking a temperature is part of an assessment, in this instance, the nurse is evaluating the efficacy of the Tylenol in treating the client's temperature. Diagnosing a fever is not a diagnosis, but a statement of fact. Planning involves setting goals and outcomes related to the problem of hyperthermia.
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