A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6 ° F (36.4 ° C). What response by the nurse is best?
a. Assess the client for more specific signs.
b. Conclude that an infection is not present.
c. Document findings and continue to monitor.
d. Request that the provider order blood cultures.
ANS: A
Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.
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