A 32-year-old female with type 1 diabetes mellitus is on postoperative day 2 following a laparoscopic cholecystectomy in a skilled nursing facility rehabilitation unit. The LPN/VN notes her vital signs: temperature 100.8°F (38.2°C), heart rate 108/min, respiratory rate 20/min, blood pressure 100/62 mmHg, and SpO2 94% on room air, compared to 98.6°F, 82/min, 16/min, and 118/76 mmHg six hours earlier. The client reports mild abdominal incisional pain rated 4/10 and states she feels "warm and tired." The surgical dressing is dry and intact. Blood glucose is 168 mg/dL. Which action should the nurse take?
- Report the vital sign trend and temperature elevation to the RN or provider promptly.
- Document the vital signs and temperature in the chart and continue routine rounding without notifying the RN or health care provider.
- Independently review the surgical report and revise the client's postoperative care plan.
- Wait until the next scheduled shift assessment in four hours to recheck vital signs.