The nurse obtains the vital signs for a client admitted 2 days ago with gram-negative sepsis: temperature 38.4°C (101.1°F), blood pressure 90/56 mm Hg, pulse 92 beats/minute, respirations 34/minute. Which of the following actions should the nurse take next?

Question

Quizplus · Accepted Answer

The client'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 client. Administration of the scheduled antibiotic and administration of acetaminophen also will be done, but they are not the highest priority for a client who may be developing ARDS.

The Nurse Obtains the Vital Signs for a Client Admitted