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At Last Measurement, the Client's Vital Signs Were as Follows

Question 3

Multiple Choice

At last measurement, the client's vital signs were as follows: oral temperature 98°F (36.7°C) , 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 103.2°F (39.6°C) , heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurse's first intervention 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) Determine if the client is feeling chilled.
D) Take the temperature by a different route.

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