Patient Data ​​​​​​ Exhibits At 2000, the unlicensed assistive personnel (UAP) reported the client's vital signs as a temperature of 102.1° F (38.9° C) orally, a heart rate of 62 beats/minute, respirations of 19 breaths/minute, and a blood pressure of 124/68 mm Hg. Which action(s) should the nurse take? Select all that apply

A. Attach the client to a cardiorespiratory monitor to measure the respiratory rate: The respiratory rate is within the normal range and does not require continuous monitoring at this stage unless other symptoms suggest deterioration. B. Assure that the blood pressure cuff is the right size: The blood pressure is within normal limits and does not indicate an issue with the cuff size at this moment. C. Alert the healthcare provider once the abnormal finding is confirmed: A temperature of 102.1° F (38.9° C) is a significant fever and could indicate worsening infection or an adverse reaction to the medication. Alerting the healthcare provider is essential for prompt evaluation and treatment adjustment. D. Retake the temperature orally: Confirming the elevated temperature with a retake is crucial for accuracy. Temperature readings can sometimes be affected by factors like improper thermometer use or external influences. E. Reassess the blood pressure: Blood pressure readings are stable and not indicative of any immediate issue requiring reassessment. F. Measure the heart rate for a full 60 seconds: The heart rate of 62 beats/minute is on the lower side of normal, and measuring for a full minute will provide a more accurate assessment of the client’s heart rate and detect any irregularities.