A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the practical nurse (PN) identifies that an unlicensed assistive personnel (UAP) has omitted a vital component of the protocol. After implementing the missing component, which action should the PN take?

A. Thrombocytopenia
Monitoring for thrombocytopenia is not directly related to the treatment of fluid volume deficit. While it is important to watch for any blood-related issues, thrombocytopenia is not a common concern specifically due to the administration of isotonic fluids like 0.9% sodium chloride. This condition would not be a primary focus in this scenario.
B. Pulmonary edema
The client should be monitored for pulmonary edema as a potential complication of fluid resuscitation. Administering large volumes of isotonic fluids can lead to fluid overload, which may cause pulmonary edema. This is especially important given the presence of pneumonia and the client's symptoms of shortness of breath and crackles in the lung fields.
C. Hypokalemia
Hypokalemia should be monitored as a potential complication of isotonic fluid administration. Although 0.9% sodium chloride does not contain potassium, patients receiving IV fluids for a significant period may develop electrolyte imbalances, including hypokalemia. Monitoring serum electrolytes is necessary to address such imbalances.
D. Alkalosis
Alkalosis is less likely to occur with isotonic fluids like 0.9% sodium chloride. This type of fluid generally does not cause acid-base imbalances such as alkalosis. The treatment for fluid volume deficit is not expected to lead to alkalosis, which is more commonly associated with metabolic alkalosis from other sources.
E. Phlebitis
Phlebitis should be monitored due to the presence of a peripheral IV access device. Long-term or large-volume infusions can irritate the vein, leading to inflammation or phlebitis. Regular inspection of the IV site for redness, swelling, or pain is necessary to prevent and manage this complication.
F. Hyponatremia
Hyponatremia is not a direct concern with isotonic fluids like 0.9% sodium chloride, as these fluids maintain sodium levels without causing a dilution effect. Monitoring sodium levels is generally more relevant in cases where hypotonic fluids are used.
G. Diarrhea and vomiting
Diarrhea and vomiting are not directly related to isotonic fluid administration. Although these symptoms can contribute to fluid volume deficits, they are not a common complication of fluid resuscitation.
H. Hyperglycemia
Hyperglycemia is not a concern with isotonic fluids like 0.9% sodium chloride. Hyperglycemia is more associated with fluids containing glucose, such as dextrose solutions. Therefore, monitoring for hyperglycemia is not necessary in this context

Applicable
Evaluating functional improvement assesses whether the additional physical and occupational therapy is effectively enhancing the client’s ability to perform activities of daily living and participate in community activities. This focuses on tangible outcomes of the therapy, such as improved mobility or independence. Measuring functional improvement helps to determine if the interventions are meeting their goals and positively impacting the client's physical abilities.

Psychological assessment
Not Applicable
While important, psychological assessment is not the primary focus when evaluating the specific outcomes of physical and occupational therapy. Psychological well-being might be a component of overall care but is not the immediate measure for the success of the physical therapies established. The main goal here is to assess the effectiveness of the physical and occupational therapy, which is more directly measured by functional and quality of life improvements.

Quality of life
Applicable
Assessing quality of life evaluates how well the client’s overall well-being is supported by the new care interventions, including their physical comfort, mental health, and ability to engage in daily activities. This broader measure considers whether the care provided enhances the client's satisfaction with their daily life and personal experiences, reflecting the success of the implemented therapies.

Financial security
Not Applicable
Financial security is not directly related to evaluating the outcomes of physical and occupational therapy interventions. It is important for overall care management but does not measure the effectiveness of specific therapies or the impact on the client’s physical functioning or quality of life. This factor is outside the scope of assessing the direct results of therapy and daily living support.

Cognitive status
Not Applicable
Cognitive status is not the main focus for evaluating the success of physical and occupational therapy. While cognitive status is relevant for overall care, the immediate goal of assessing the effectiveness of the physical therapies is to see improvements in functional abilities and quality of life. Cognitive assessments are important but not directly related to the specific goals of physical and occupational therapy outcomes