Editing Fundamentals of Nursing – LPN Practice Questions (section)

==Question 4==
The licensed practical nurse measures an adult patient's vital signs and obtains a temperature of 38.6 degrees Celsius (101.5 degrees Fahrenheit), a pulse of 112 beats per minute, respirations of 24 breaths per minute, blood pressure of 96 over 58 millimeters of mercury, and oxygen saturation of 91 percent on room air. The patient's morning values were normal. What should the nurse do first?
# Document the values and recheck them in four hours.
# Report the findings to the registered nurse promptly.
# Encourage the patient to drink fluids and rest.
# Ask assistive personnel to repeat the vital signs.

'''Answer:''' 2. Report the findings to the registered nurse promptly.

''Rationale:'' This is a significant change from the patient's own baseline across several parameters and suggests possible infection or sepsis. Prompt reporting to the registered nurse allows assessment, provider notification, and timely treatment. Option 1 delays care through a dangerous window. Option 3 is a supportive measure that does not address the acute change. Option 4 delays escalation and assigns the recheck of an unstable patient to unlicensed staff, which is inappropriate.