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?
Rationale: Based on the confusion and drop in systolic blood pressure, the client may be becoming septic. The nurse should obtain blood cultures to determine if bacterial infection is triggering the response; this will also indicate which antibiotics would be effective. Fever can decrease oxygenation, so the client should be placed on oxygen. Antipyretics should be administered, and the nurse should follow up and recheck the temperature in 30 minutes or so to see if it is decreasing. The client should rest and avoid physical activity. There is no need to make the client NPO; fluids help with hydration and should be encouraged if the client can drink. Although the client may want a blanket if experiencing chills, the room temperature should be decreased and excess blankets removed.
