A client with a Stage II pressure injury on the sacrum is most likely to present with which finding?

A. Ask the client to perform IS: Encouraging incentive spirometry promotes lung expansion and prevents atelectasis, but it is an intervention rather than an assessment. Performing this action without first gathering additional clinical data does not provide information about the underlying cause of the increased respiratory rate or the client’s oxygenation status.

B. Notify the provider: Notifying the provider is a critical step when a patient’s condition may be deteriorating, but it occurs after the nurse has collected and interpreted objective data. Immediate reporting without first assessing vital signs and oxygenation may result in incomplete communication and delay targeted interventions.

C. Obtain vitals and pulse ox: Gathering vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation, allows the nurse to quantify the client’s current status and identify potential hypoxia, infection, or other causes of tachypnea. This reflects both data collection and clinical reasoning, forming the basis for prioritizing further interventions and communicating effectively with the provider.

D. Call rapid response: Activating the rapid response team is appropriate for signs of acute deterioration, but an increased respiratory rate of 24 alone may not meet criteria for immediate team activation. The nurse should first gather additional assessment data to determine the severity of the situation and the appropriate level of intervention.

A. Apply the sensor to the client's sternum: The sternum is not a reliable site for standard pulse oximetry because it lacks a strong pulsatile arterial signal. Reflectance sensors can be used on the chest in specific settings, but this is generally less accurate for routine oxygen saturation monitoring compared with peripheral sites with good perfusion.

B. Place the sensor on the client's right index finger: The right index finger is the typical site for pulse oximetry; however, in this client with peripheral vascular disease, slow capillary refill and a weak pulse indicate poor perfusion. Using this site could produce inaccurate readings, including falsely low SpO₂ values or signal loss, making it inappropriate in this situation.

C. Apply the sensor to the client's right great toe: The toe can sometimes be used if upper extremities are unavailable, but peripheral vascular disease may also compromise perfusion in the lower extremities, especially in the presence of arterial disease. This could also result in unreliable readings.

D. Place the sensor on the client's earlobe: The earlobe provides a site with more consistent perfusion that is less affected by peripheral vascular disease. It is suitable for pulse oximetry in patients with weak or compromised distal pulses, allowing accurate measurement of oxygen saturation while bypassing poorly perfused fingers or toes.