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The nurse in the medical surgical unit checks the temperature of an older adult diagnosed with pneumonia.The client’s temperature is 100.8. The nurse provides oral hydration to the older adults and encourages fluid intake. Four hours later, the nurse rechecks the temperature and notes that it is 100.8. which nursing action should the nurse take at this time.

a. Document the temperature

b. Increase the intravenous fluids

c. Notify the healthcare provider

d. Continue hydration and check temperature in 4hrs

Answer :

The nursing action that the nurse should take when the rechecked temperature is 100.8 is to document the temperature.

In order to ensure continuity of care and to maintain proper monitoring of the patient, it is important to document the temperature. This is because it serves as an important reference for future decisions related to the client's care

It is not an emergency situation. The client's temperature is within the range of low-grade fever. Hence, it is not necessary to notify the healthcare provider immediately, as it is not an emergency situation. Instead, it is better to continue with hydration and monitor the client's condition.

IV fluids are not necessary as the client's temperature is not high enough to suggest dehydration.

It is important to monitor the client's temperature to ensure it does not rise further and to make sure that the oral hydration provided by the nurse is helping the patient stay hydrated. The nurse should continue hydration and check temperature in 4 hours to monitor the client's condition.

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