HESI RN Med surg proctored exam 3
The nurse is obtaining vital sign measurements every 15 minutes for a client who had an emergency appendectomy and currently has a temperature of 101.4°F (38.6°C). Which vital sign measurements should the nurse report to the healthcare provider?
Explanation & Rationale
Choice A reason: These vital signs are within normal limits and do not indicate an immediate concern that requires reporting to the healthcare provider.Choice B reason: This set of vital signs shows a heart rate of 110 beats/minute, which is tachycardia, and a blood pressure of 88/56 mmHg, which is hypotension. Both of these findings, combined with the client's fever, could indicate sepsis or other complications that require immediate attention.Choice C reason: These vital signs are relatively stable and do not indicate a critical issue that requires immediate reporting.Choice D reason: While these vital signs show an elevated respiratory rate, they are not as critical as the vital signs in Choice B, which show hypotension and tachycardia.
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