Pathophysiology · practice question

A 73-year-old client on a telemetry unit is being evaluated for nursing care related to acid-base imbalance. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Which finding requires the nurse to intervene immediately?

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Routine data unchanged from the prior assessment.A stable, long-standing finding that matches the expected care plan.The new finding that temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion.A comfort request with unchanged vital signs and no new symptoms.

Answer and explanation

Correct answer

C. The new finding that temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion.

Why

Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.

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A 73-year-old client on a telemetry unit is being evaluated for nursing care related to acid-base imbalance. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Which finding requires the nurse to intervene immediately?

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