Which interventions would the nurse implement immediately for a patient who is slightly confused, had an increased temperature and pulse over the last two shifts, and has a current temperature of 102° F (38.9° C), pulse of 96, respiratory rate of 22, and oxygen (O2) saturation of 93%? Select all that apply. One, some, or all responses may be correct.
A. Auscultating all lung fields
B. Immediately placing the patient in isolation
C. Obtaining blood cultures from two different sites
D. Checking urine for cloudiness, odor, and discoloration
E. Notifying the primary health care provider of the patient's status
Answer (1)
The nurse should immediately auscultate lung fields, obtain blood cultures from two different sites, and notify the primary healthcare provider regarding the patient's condition. These interventions prioritize assessing respiratory status and potential infections. Other actions can follow these high-priority steps. ;
