Asked by tatiana vayserberg on Jun 27, 2024
Verified
A 42-year-old client has a rectal temperature reading of 39.2°C (102.6°F) .Her blood pressure has decreased from 124/76 to 118/70 since taken 4 hours earlier.Her pulse rate has increased from 68 to 78.The nurse's initial best action is to:
A) Document the vital signs and continue with her assessment
B) Contact the provider immediately due to the alarming changes in the vital signs
C) Obtain a pulmonary artery temperature reading before initiating any type of treatment
D) Ask the NAP to obtain another set of vital signs in 4 hours
Rectal Temperature
A method of measuring body temperature by inserting a thermometer into the rectum, considered quite accurate.
Pulmonary Artery
The large artery that carries deoxygenated blood from the heart to the lungs for oxygenation.
Vital Signs
Measurements of the body's basic functions, including temperature, blood pressure, pulse, and respiratory rate.
- Learn the techniques for evaluating postoperative vital signs and determining the correct nursing interventions.
Verified Answer
MS
Martina SaberJun 30, 2024
Final Answer :
D
Explanation :
The nurse simply needs to continue monitoring the patient's vital signs.The patient's temperature of 102.5°F (39.2°C)is not considered an emergency temperature for an adult.A moderate fever of up to 103°F (39.4°C)is considered a mechanism by which the body fights off infection.The metabolic rate is expected to increase with a fever,which will lead to an increase in the pulse rate.Blood pressure is more likely to decrease with a fever because of peripheral vasodilation.
Learning Objectives
- Learn the techniques for evaluating postoperative vital signs and determining the correct nursing interventions.