A client presents with redness, swelling, crusting, and scaling of the left pinna with scanty purulent discharge the day after swimming. The client has pain when the pinna and tragus are palpated. What condition should the nurse suspect?

A. The respiratory rate is not provided in the assessment data. Because no abnormal value is documented, respirations cannot be identified as concerning based on the available information. There is no evidence of tachypnea, bradypnea, or respiratory distress.

B. A blood pressure of 90/58 mmHg is hypotensive. In a 74-year-old client, hypotension is especially concerning because it may indicate decreased organ perfusion. Potential causes include dehydration, blood loss, sepsis, medication effects, or cardiac dysfunction. Older adults have decreased physiologic reserve, so low blood pressure increases the risk for dizziness, falls, syncope, kidney injury, and altered mental status. This finding requires immediate assessment.

C. A pain rating of 1/10 indicates minimal discomfort. This level of pain is mild and not physiologically destabilizing. It does not suggest acute distress or hemodynamic compromise and therefore is not a priority concern.

D. A heart rate of 118 beats per minute is tachycardia. Normal adult heart rate ranges from 60 to 100 beats per minute. Tachycardia in this context is concerning, especially when paired with hypotension. The elevated heart rate may represent a compensatory mechanism in response to low blood pressure in an attempt to maintain cardiac output and organ perfusion. This combination raises concern for early shock, hypovolemia, or other circulatory instability and requires prompt follow-up.

E. A temperature of 98.9°F (37.1°C) is within normal limits. There is no evidence of fever or hypothermia. This value does not indicate infection or systemic instability.

F. An oxygen saturation of 97% on room air is normal and indicates adequate oxygenation. There is no sign of hypoxia or respiratory compromise.

A. There is no evidence of inappropriate behavior by the UAP. The UAP accurately reported the vital signs. There is no indication of misconduct or negligence that would require reporting to a manager.

B. Although one value is abnormal, the nurse should not delegate reassessment of an abnormal finding back to the UAP. When abnormal data are reported, the registered nurse is responsible for validating and further assessing the finding personally. Re-delegating does not meet the RN’s accountability for clinical judgment.

C. A pulse oximetry reading of 91% on room air is below normal (normal is 95–100%), indicating mild hypoxemia. However, before initiating an intervention such as oxygen therapy, the nurse must first validate the abnormal finding. Pulse oximetry readings can be affected by poor probe placement, cold extremities, nail polish, motion, or equipment error. Immediate oxygen administration without reassessment is premature.

D. A pulse oximetry of 91% is abnormal and requires follow-up. The nurse’s first action should be to personally reassess the oxygen saturation to validate the accuracy of the reading. This includes checking probe placement, ensuring proper perfusion, and assessing the client’s respiratory status. Once validated, appropriate interventions such as oxygen therapy can be initiated if necessary.