The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client’s vital signs have been stable for the last 24 hours, but the client now has a temperature of 38.4°C (101.1°F), a heart rate of 116, and a respiratory rate of 26 breaths/min.
The client has an IV infusion running at a keep open rate. The nurse contacts the physician and receives the following prescriptions (see chart below). Which of the following prescriptions should the nurse implement first?
1. Obtain blood cultures.
2. Increase the rate of the intravenous infusion.
3. Obtain CT of abdomen.
4. Chart vital signs.
The nurse should first obtain the blood culture because subsequent treatment will be dependent on the results.
The client has an intravenous infusion; the physician did not write a prescription to increase the infusion rate. Unless indicated otherwise, the nurse can take the client’s vital signs after completing scheduling the CT scan and other laboratory work.
CN: Reduction of risk potential; CL: Synthesize