A 52-year-old woman on the rehabilitation unit is recovering from a hip fracture repair and has cellulitis of the surgical leg treated with a newly prescribed daily oral antibiotic. Her baseline temperature 2 hours ago was 37.0°C (98.6°F). The LPN/VN now finds: temperature 39.4°C (102.9°F), heart rate 118 beats/min, respiratory rate 24 breaths/min, blood pressure 96/58 mm Hg, SpO2 94% on room air, and the client is diaphoretic and slightly confused about the day of the week. The surgical dressing is dry and intact with a well-approximating incision line. The nurse applies a cooling blanket per protocol. What should the LPN/VN do next?
- Focus care on the intact, well-healing surgical incision noted during the check.
- Report the vital sign changes and new confusion to the RN or provider promptly.
- Leave the cooling blanket in place continuously until shivering stops on its own.
- Document the elevated temperature and altered mental status in the chart only.