The nurse obtains the following vital signs on an adult patient: T.100.6°F BP 100/60,HR 110,respirations 36.What is the first action by the nurse?

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In this item,all vital signs values are slightly abnormal; however,the most significant abnormality is the respiratory rate of 36 breaths/min.Respiratory rate is a measure of the patient's general condition,but rate alone is not a good indicator of the adequacy of respirations or oxygenation.The nurse must also assess other characteristics of the respirations.If oxygenation must be carefully monitored or there is a concern regarding oxygenation,use a pulse oximeter to measure the patient's oxygenation saturation.The nurse may need to administer oxygen to this patient,given the respiratory rate of 36 breaths/min; however,the first action is to obtain a pulse oximeter reading.There is no evidence that the patient needs either oral or IV fluids.

The Nurse Obtains the Following Vital Signs on an Adult