A health care provider has ordered vital signs every 4 hours.

The client’s 8:00 AM temperature was 99° F (37.2° C).

At 10 AM, the client reported chills.

A nurse takes the client’s temperature again. Which type of nursing action does this exemplify?

This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.

Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.

Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.

Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.

Normal ranges for vital signs are as follows :

• Blood pressure: 90/60 mm Hg to 120/80 mm Hg
• Breathing: 12 to 18 breaths per minute
• Pulse: 60 to 100 beats per minute
• Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)

“I have limited my alcohol intake before bedtime.”. This statement shows that the client understands that alcohol can interfere with sleep quality and quantity. Alcohol can disrupt the normal sleep cycle and cause frequent awakenings, nightmares, or insomnia.

Choice A is wrong because sleeping in most mornings can disrupt the regular sleep schedule and make it harder to fall asleep at night. It is better to keep a consistent bedtime and wake time, even on weekends.

Choice B is wrong because working on the computer before going to bed can expose the client to blue light, which can suppress the production of melatonin, a hormone that regulates sleep. It is better to avoid screens and other stimulating activities at least an hour before bedtime.

Choice D is wrong because watching television for 1 hour before sleeping can also expose the client to blue light and interfere with sleep onset. It is better to engage in relaxing activities such as reading, listening to soothing music, or meditating before sleeping.