Difficulty: Medium
Average Score: 77%
Simulated
The nurse is caring for a client who was admitted with an upper respiratory infection. The client's temperature is 102.4┬░F, and he is confused. In the last 2 hours, systolic blood pressure has dropped from 138 to 90. The nurse should perform which intervention? Select all that apply.
Correct answer
A,C,D,E
Rationale
Fever, confusion, and hypotension suggest sepsis, requiring blood cultures (A), oxygen (C), antipyretics (D), and rest (E). NPO (B) is unnecessary, and warming blankets (F) may worsen fever.