A patient’s oral temperature is 38.5°C, and the patient is shivering after returning from a cold shower. What is the most appropriate next action?
Correct answer: C. Assess the patient and confirm the temperature after warming
- A. Record the temperature without further assessment
- B. Recheck the temperature immediately using the same method
- C. Assess the patient and confirm the temperature after warming
- D. Give an antipyretic before checking other findings
Explanation
Shivering and environmental exposure can affect the temperature reading and also indicate a possible developing fever. The nurse should assess the patient, allow the patient to warm safely, and confirm the reading according to facility procedure before interpreting the result or giving treatment.
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About Vital Signs and Monitoring
Vital signs include temperature, pulse, respiration, blood pressure, oxygen saturation and pain assessment. Coverage includes correct measurement sites and techniques, normal adult ranges, factors that alter readings, trends in patient observations, and the difference between an abnormal finding that needs reassessment and one requiring immediate reporting.
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