A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next
a) Administers oxygen by nasal cannula at 2 liters per minute
b) Contacts the admitting physician
c) Re-assesses the vital signs
d) Calls the Rapid Response Team
Answer: A
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