At last measurement, the client's vital signs were as follows: oral temperature 98F (36.7C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg.
Four hours later, the vital signs are as follows: oral temperature 103.2F (38.5C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should the nurse's first intervention be at this time?
a. Ask the client whether he has had a warm drink in the last 30 minutes.
b. Notify the primary care provider of the client's temperature.
c. Ask the client whether he is feeling chilled.
d. Take the temperature by a different route.
Question 2
The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home. It would be most important for the nurse to:
a. Ask the client to demonstrate the use of the blood pressure device
b. Explain the importance of frequent calibration of the device
c. Give the client a chart to record his blood pressure readings
d. Provide written instructions of the information taught