A nurse assesses a client who is hospitalized for botulism. The client's vital signs are temperature: 99.8 ° F (37.6 ° C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take?
a. Decrease stimulation and allow the client to rest.
b. Stay with the client while another nurse calls the provider.
c. Increase the client's intravenous fluid replacement rate.
d. Check the client's blood glucose and administer orange juice.
ANS: B
A client with botulism is at risk for respiratory failure. This client's respiratory rate is slow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. The nurse should monitor and document the IV infusion per protocol, but this client does not require additional intravenous fluids. Allowing the client to rest or checking the client's blood glucose and administering orange juice are not appropriate actions.
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