A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.

Choice A reason: Checking the blood pressure every five minutes for one hour is important, especially if the blood pressure is unstable. However, this action does not address the immediate issue of the client’s low temperature, which needs to be verified and addressed promptly to prevent complications such as hypothermia.

Choice B reason: Taking the client's temperature using another method is crucial. The extremely low tympanic temperature reading may not be accurate, and confirming the client's core body temperature is essential. Hypothermia can lead to serious complications, including altered cardiovascular and respiratory function, and needs to be managed promptly.

Choice C reason: Raising the head of the bed to 60 to 90 degrees is not appropriate in this situation. Elevating the head of the bed is typically done to improve respiratory function or decrease intracranial pressure, but it does not address the potential issue of hypothermia indicated by the low temperature reading.

Choice D reason: Asking the client to cough and deep breathe is a good practice to prevent postoperative complications such as atelectasis, but it is not the priority intervention in this scenario. The immediate concern is verifying the client's temperature to rule out or address hypothermia.

Choice A reason: Administering PRN pain medication can help manage the client's discomfort, but it does not address the underlying cause of the pain. It is essential to assess and identify the source of the pain before administering pain relief. Providing pain medication without a thorough assessment may mask symptoms of a serious underlying issue.

Choice B reason: Observing the leg for swelling is important, as swelling can indicate complications such as compartment syndrome or infection. However, it is not the first action the nurse should take. While swelling is a significant sign, assessing blood flow to the extremity is more critical and should be prioritized.

Choice C reason: Assessing peripheral pulses is the correct first intervention. The presence of foot pain in a client with an external fixation device for a fractured femur could indicate compromised blood flow to the lower extremity. Assessing the peripheral pulses will help determine if there is adequate circulation. If pulses are weak or absent, it may suggest a serious vascular issue that requires immediate intervention to prevent further complications such as tissue ischemia or necrosis.

Choice D reason: Auscultating blood pressure is a routine assessment but does not directly address the immediate concern of left foot pain in this scenario. Blood pressure assessment is important for overall health monitoring but is not the priority when dealing with a possible vascular complication in the affected limb. Ensuring adequate blood flow to the extremity takes precedence.