Author Question: At last measurement, the client's vital signs were as follows: oral temperature 98F (36.7C), ... (Read 55 times)

rayancarla1 · **on:** Jul 23, 2018

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

A 42-year-old client has a rectal temperature reading of 39.2C (102.6F). Her blood pressure has decreased from 124/76 to 118/70 since taken 4 hours earlier. Her pulse rate has increased from 68 to 78 . The nurse's initial best action is to:

a. Document the vital signs and continue with her assessment
b. Contact the provider immediately due to the alarming changes in the vital signs
c. Obtain a pulmonary artery temperature reading before initiating any type of treatment
d. Ask the NAP to obtain another set of vital signs in 4 hours

ndhahbi · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

A
With a fever, the heart rate and respiratory rate are usually elevated. In this case, they are within normal limits, so the nurse should wonder about the accuracy of the temperature reading and validate it in some way. Because having a hot drink is a common cause of false readings, the nurse should determine whether that has occurred before retaking or otherwise validating the reading.

Answer to Question 2

D
The nurse simply needs to continue monitoring the patient's vital signs. The patient's temperature of 102.5F (39.2C) is not considered an emergency temperature for an adult. A moderate fever of up to 103F (39.4C) is considered a mechanism by which the body fights off infection. The metabolic rate is expected to increase with a fever, which will lead to an increase in the pulse rate. Blood pressure is more likely to decrease with a fever because of peripheral vasodilation.