A charge nurse on a mental health unit is receiving a change of shift report for a group of clients.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first collect data from

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due to

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and

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.

B.Oxygen saturation (92% on room air): A drop in oxygen saturation from 96% to 92% indicates impaired gas exchange, which may require oxygen therapy or further evaluation for respiratory compromise.
C. Respiratory assessment (crackles, chest tightness, productive cough with blood): Crackles and productive cough with hemoptysis are concerning for possible tuberculosis (TB) or another serious respiratory infection. Immediate notification ensures timely isolation and further diagnostic testing.
D. Temperature (38.8°C/101.8°F): The elevated temperature indicates a possible infection or worsening inflammatory process, especially concerning given the night sweats and recent international travel history.
E. Neurological status (lethargy): The progression from an alert state to lethargy suggests potential worsening of the client’s condition, possibly due to hypoxia, infection, or sepsis. Early identification is critical for preventing deterioration.
F. X-ray results (calcification in upper lobes): Calcifications in the upper lung lobes are characteristic of previous or latent TB infection. This, combined with the client’s current symptoms, requires prompt reporting to initiate appropriate infection control measures.

Findings Not Reported:
A.Bowel pattern (normoactive, last BM this morning): The bowel pattern is normal and not immediately relevant to the acute respiratory concerns.
G. Heart rate (114/min): Though elevated, the heart rate is likely a secondary response to the fever and respiratory compromise. While important to monitor, it does not warrant immediate provider notification independently.

A. Weigh the client every other day. Daily weights are essential for monitoring fluid retention in pulmonary edema.
B. Place the client in a supine position. The client should be placed in a high Fowler's position to improve lung expansion and reduce dyspnea.
C. Encourage the client to ambulate three times per day. Clients with pulmonary edema are often too compromised to ambulate frequently. Rest is initially preferred.
D. Report urine output less than 30 mL/hr. Low urine output may indicate decreased renal perfusion, fluid retention, or worsening heart failure, all of which require prompt reporting.