The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? (Select all that apply)

A. Take the blood pressure:

Assessing blood pressure is a critical initial step when a patient is experiencing dyspnea. It helps provide information about the patient's overall cardiovascular status, which is essential in determining the severity of the dyspnea and guiding subsequent interventions.

B. Remove the pillow from under the patient’s head:

Removing the pillow may be a relevant intervention if the patient is in a position that could be contributing to respiratory distress. However, the priority is to first assess vital signs, particularly blood pressure, to gather information about the patient's cardiovascular status.

C. Elevate the foot of the bed:

Elevating the foot of the bed may be a consideration if the dyspnea is related to conditions such as heart failure, where raising the legs can help reduce venous return and decrease the workload on the heart. However, the initial priority is to assess blood pressure to guide appropriate interventions.

D. Elevate the head of the bed:

Elevating the head of the bed may be beneficial for patients with respiratory distress to improve ventilation and oxygenation. While this intervention may be appropriate, the first action should be to assess vital signs, particularly blood pressure, to gain an overall understanding of the patient's condition.

A. Wait 30 min and return to measure the oral temperature:

Waiting 30 minutes may not be necessary. It's more practical to take immediate steps to address potential factors affecting the reading.

B. Provide the client a sip of warm water, wait 5 min, and measure the temperature:

This can be a reasonable and practical approach to stimulate blood flow in the oral cavity and achieve a more accurate oral temperature reading.

C. Document that the nurse was unable to measure the client’s temperature:

Before documenting an inability to measure the temperature, the nurse should attempt appropriate interventions, such as warming the oral cavity or using an alternate route

D. Determine if the client has eaten or drank within the last 15 minutes:

Eating or drinking something cold shortly before taking an oral temperature can result in a lower reading. Checking for recent intake is important to ensure the accuracy of the measurement.

E. Use an alternate route (i.e., axillary, rectal) to take the client’s temperature:

If the oral temperature reading remains difficult to obtain or is not reliable, using an alternate route may be necessary. However, this depends on the client's condition, the reason for the temperature measurement, and the healthcare facility's protocols.