Question

A nurse is monitoring a person being treated for a serious infection. Their vital signs are: Temperature 102 °F Heart rate (HR) of 120 beats per minute (bpm) Breathing rate (RR) 25 per minute Blood pressure (BP) 90/60 The blood test results are not back yet. What should this nurse do?

Answer 1

The nurse should notify the physician, provide supportive care, and monitor the patient for signs of deterioration, as the vital signs suggest a serious infection, possibly sepsis.

Step-by-step explanation:

The nurse monitoring a person with a serious infection showing a temperature of 102 °F, heart rate of 120 bpm, breathing rate of 25 per minute, and blood pressure of 90/60 should recognize these vital signs may be indicative of disease and possibly sepsis. Given these abnormal vital signs, the nurse should immediately inform the physician, provide supportive care to manage fever and maintain circulation, and closely monitor the patient for signs of deterioration, such as decreased oxygen saturation, altered mental status, or further decline in blood pressure. Further interventions should be prepared while awaiting lab results to determine the appropriate treatment to target the infection effectively.

Answer 2

The nurse should treat the patient's elevated temperature, heart rate, breathing rate, and low blood pressure as signs of a possible systemic infection like sepsis and initiate immediate medical interventions such as IV fluids and antibiotics, while continuously monitoring vital signs.

Step-by-step explanation:

Given the patient's vital signs of high temperature (102 °F), elevated heart rate (120 bpm), increased breathing rate (25 per minute), and low blood pressure (90/60), the nurse should consider these changes indicative of a serious condition, possibly sepsis.

Although the blood test results are pending, the nurse should act swiftly due to the signs of a systemic infection. Immediate medical intervention, including administration of intravenous fluids and potentially broad-spectrum antibiotics, should be initiated following hospital protocols, and continuous monitoring of the vital signs is essential.

Consultation with a physician to evaluate the need for further medication, such as antipyretics to manage fever, or oxygen supplementation, might also be necessary.