Difficulty: Medium
Average Score: 87%
Simulated
The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing intervention?
Correct answer
C
Rationale
The correct answer is C because the vital signs are abnormal (e.g., elevated temperature, high heart rate). Immediate nursing intervention is needed to assess for potential infection or other serious conditions. Clients A, B, and D do not show signs of immediate distress based on vital signs. Client A has slightly elevated blood pressure, client B has normal vital signs, and client D has vital signs within normal limits.