A triage nurse in the emergency department assesses a client who complains of 7/10 abdominal pain and states. "I had a temperature of 103.9 Fat home." Which action should the nurse take first?

Rationale: A. While fever reduction can improve patient comfort, administering acetaminophen before assessing current vital signs is inappropriate. Fever is a clinical sign that may indicate a serious infection or sepsis. Giving medication first could mask important symptoms such as elevated temperature or tachycardia, potentially delaying recognition and treatment of a life-threatening condition. B. Triage nurses must follow the ABCDE framework (Airway, Breathing, Circulation, Disability, Exposure) and prioritize immediate assessment of hemodynamic stability. The client reports a high fever of 103.9°F at home and moderate abdominal pain rated 7/10, which may indicate a serious infection such as pyelonephritis, appendicitis, or sepsis. Assessing current vital signs—including temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation—provides crucial information to identify acute instability and determine the urgency of care. Early recognition and prioritization of high-acuity patients are critical in the emergency setting. C. Although urinalysis may be necessary to evaluate for a urinary tract infection or other causes of fever and abdominal pain, collecting diagnostic specimens is secondary to assessing the client’s immediate physiological status. If the client is unstable, diagnostic tests can be delayed until after vital signs are assessed and stabilization is initiated. D. Providing this information without first assessing vital signs is unsafe. The client may have a potentially life-threatening condition that requires immediate intervention. Delaying assessment could result in clinical deterioration and poor outcomes.