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 (38.5°C),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?

Question

Quizplus · Accepted Answer

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.

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