A patient’s temperature is 38.2°C, but the patient is alert, breathing comfortably and has no other new symptoms. What should the nurse do first?
Correct answer: A. Recheck the temperature using the same device
- A. Recheck the temperature using the same device
- B. Call the rapid response team immediately
- C. Give an antipyretic without a prescription
- D. Document the reading without further assessment
Explanation
The nurse should verify an unexpected abnormal finding and assess the patient before deciding whether escalation is needed. Immediate emergency action is guided by instability, such as altered consciousness or breathing difficulty, not fever alone.
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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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