A nurse is making the initial rounds to the clients assigned to her care during her shift. After taking all their vital signs, the nurse reviews the vital signs obtained from the clients. Which of the following clients should the nurse focus on first?
Explanation
Answer: B - The client with increased respiratory rate should be evaluated first. This is followed by the client with increased temperature. A blood pressure of 150/80mmHg and HR of 75 is within the normal range. Assess for shortness of breath, cyanosis, and altered mental status in the tachypneic client. In the febrile client, recheck the temperature after 15 minutes, if still hyperthermic, assess for possible cause of fever.
