The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the patient's temperature is 96.8°F (36°C), whereas at 4 PM the preceding day, it was 98.6°F (37°C). What should the nurse do?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: C

Rationale: Blood pressure is a core vital sign, alongside temperature, pulse, and respiration, reflecting cardiovascular health by measuring arterial force. Mental status is assessed separately, often via neurological exams, not as a vital sign. Visual acuity evaluates eyesight, unrelated to immediate physiological stability. Urinary output monitors kidney function but isn't a standard vital sign, though it's tracked in critical care. The answer key confirms C, aligning with nursing fundamentals (e.g., Taylor's text), where vital signs are immediate indicators of life-sustaining functions, distinguishing BP's role in routine assessments from other metrics.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.