Difficulty: Medium
Average Score: 90%
Simulated
A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
Correct answer
B
Rationale
The nurse should address the temperature (Choice B) immediately because it is below the normal range (normal range is around 97-99┬░F). A low body temperature, such as 94.8┬░F, can indicate hypothermia, which is a medical emergency requiring prompt intervention to prevent complications like organ dysfunction or cardiac arrest. Addressing the temperature first is crucial to prevent further deterioration of the patient's condition.
Other choices are not as urgent:
A: Respiratory rate (12 breaths per minute) is within the normal range.
C: Apical pulse (58 beats per minute) is slightly lower but not immediately life-threatening.
D: Blood pressure (106/56 mmHg) is on the lower side but not acutely concerning.
Other choices are not as urgent:
A: Respiratory rate (12 breaths per minute) is within the normal range.
C: Apical pulse (58 beats per minute) is slightly lower but not immediately life-threatening.
D: Blood pressure (106/56 mmHg) is on the lower side but not acutely concerning.