A Patient Admitted 2 Days Ago with Gram-Negative Sepsis Has

question 19

Multiple Choice

A patient admitted 2 days ago with gram-negative sepsis has the following assessment data: temperature 38.3°C,blood pressure 90/56 mm Hg,pulse 92 beats/min,respiration 34 breaths/min.Which action should the nurse take first?

• A) Obtain oxygen saturation using pulse oximetry.
• B) Document the vital signs,and continue to monitor.
• C) Administer as-needed acetaminophen (Tylenol)650 mg.
• D) Notify the physician of the patient's assessment data findings.

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