Question

You are assigned to take vital signs on 12 residents before they go to the dining room for breakfast. Ms. Jones who is the 2nd patient on your list has an oral temperature of 103.5 degrees. Her pulse is 110 and her respirations are 32. What should the nursing assistant do next:

Select one or more:
a. Cover Ms. Jones with an extra blanket and give her some water. Complete the other vital signs and then report the abnormal findings to the nurse

b. Tell Ms. Jones' daughter who is at the bedside to find the nurse and report the findings

c. Immediately report the vital signs finding to the nurse

d. Finish taking the other assigned vital signs and then report Ms. Jones' abnormal findings

Answer 1

The nursing assistant should immediately report Ms. Jones' elevated temperature and abnormal vital signs to a nurse, as they indicate a potential serious condition requiring urgent attention.

Step-by-step explanation:

When a patient, such as Ms. Jones, exhibits vital signs with an elevated temperature of 103.5 degrees, a pulse of 110, and respirations of 32, the priority action is to immediately report the vital signs findings to the nurse. These readings indicate a potential serious condition that requires prompt medical attention. It is not appropriate to cover Ms. Jones with an extra blanket, which could further increase her temperature. It is also not appropriate to delay reporting by finishing taking vital signs of other residents. While informing a family member may be helpful, the direct reporting to a healthcare professional should not be bypassed or delayed.