The nurse is caring for a patient with the following vital signs:

• Temperature: 98.9° F
• Pulse: 94
• Respirations: 20
• Blood pressure: 144/94
• Pulse oximetry: 94%

What is the priority action of the nurse?

A. Ask the patient to rate the pain on a 0-to-10 scale. Pain is subjective, and the first step in pain management is assessment. Asking the patient to rate their pain helps determine the severity and whether adjustments to pain management are needed.
B. Call the physician or health care provider immediately. Contacting the provider may be necessary if the pain is uncontrolled, but the nurse must assess the pain level first before deciding if intervention is needed.
C. Check the patency of the patient's intravenous line. While an IV line is essential for PCA function, the priority is assessing the patient’s pain level before troubleshooting the equipment.
D. Speak to the patient in a calming tone to reduce anxiety. Although a calm demeanor is beneficial, it does not address the patient’s pain directly. Pain assessment is the first priority.

A. Axillary. The axillary method is less accurate because it measures surface temperature, which can be influenced by environmental factors and is typically lower than core temperature.
B. Rectal. The rectal route provides the most accurate core temperature measurement because it closely reflects internal body temperature and is less affected by external conditions. It is commonly used in critically ill patients and infants when precise measurements are needed.
C. Forehead. Forehead (temporal artery) thermometers provide a non-invasive method of measuring temperature but can be less accurate due to external factors like sweating or ambient temperature changes.
D. Oral. Oral temperature is commonly used and provides a good estimate of core temperature, but factors like recent eating, drinking, or mouth breathing can affect accuracy. Rectal temperature remains the most precise method.