The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next?

Question

Quizplus · Accepted Answer

The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing; the nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Documentation and continued monitoring of the vital signs are needed but do not constitute an adequate response to the patient situation. Tylenol administration is appropriate but not the highest priority for this patient.

The Nurse Obtains the Vital Signs for a Patient Admitted