The nursing assistant is taking vitals for a client on mechanical ventilation. Which of the following findings should the nursing assistant report to the nurse immediately?

  1. respiratory rate 26 breaths/minute
  2. heart rate 82 beats/minute
  3. blood pressure 152/86 mmHg
  4. temperature 102.1°F
Number 4 is correct.
Rationale: Clients on mechanical ventilation are susceptible to infection because bacteria and viruses can enter the endotracheal tube and infect the lower respiratory system. An increased temperature could indicate a possible infection and should be reported immediately. The other vital signs are findings that would be considered within normal limits.