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NCLEX-RN

Category - Reduction of Risk

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The nurse is making the last round for her shift, and she takes the vital signs of the client admitted because of gastroenteritis. The client’s vital signs are: BP 130/89 mmHg, PR 96, RR 28, Temp 36.2°C. What is the nurse’s next action?

Document the vital signs.
Review the client’s previous vital signs.
Report the increased pulse rate and respiratory rate.
Recheck the vital signs after 15 minutes.

Explanation

Answer: D - The nurse must recheck the vital signs after 15 minutes. If the temperature is unchanged, the nurse must employ interventions to increase the temperature. All other parameters are within normal range and should be documented accordingly.

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