While sponging a client who has a high fever, the nurse observes the client shivering. Which is the nurse's priority action?
a. Administering oral acetaminophen
b. Placing a heated blanket on the client
c. Stopping sponging the client
d. Warming up the water and continuing sponging
C
Shivering is an indication that the client is being cooled too fast. The nurse should stop the sponging and immediately assess the client's temperature. The sponging should not continue, even if the temperature of the water is increased. Acetaminophen should not be administered without knowledge of the client's temperature, nor should a heated blanket be applied.
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