A nurse in a walk-in clinic is caring for a client.

Which of the following six findings should the nurse report to the provider? Select the 6 findings that require immediate follow-up.

1300:

• Temperature 39.1° C (102.4° F)
• Heart rate 115/min
• Respiratory rate 30/min
• Blood pressure 99/58 mm Hg
• Oxygen saturation 93% on room air

1330:

• Temperature 39.2° C (102.5° F)
• Heart rate 118/min
• Respiratory rate 28/min
• Blood pressure 91/52 mm Hg
• Oxygen saturation 95% on 2 L/min nasal cannula
• Heart rate
• Skin turgor
• Temperature
• Heart sounds
• Blood pressure
• COVID test results
• Orientation
• Lung sounds

Choice A reason:
Documenting the fluid infusion in the client's chart: While documenting the fluid infusion is important, assessing the client's vital signs should take priority to ensure their immediate safety and well-being.
Choice B reason:
Completing an incident report is incorrect Completing an incident report is a necessary step to document the error and initiate appropriate follow-up actions, but it should come after assessing the client's condition.
Choice C reason
Obtaining the client's vital signs is the correct answer. The correct first action for the nurse to take in this situation is to obtain the client's vital signs. Administering an excessive amount of IV fluid could potentially have adverse effects on the client's cardiovascular system, including fluid overload, electrolyte imbalances, and changes in blood pressure. Monitoring the client's vital signs will help assess their current condition and any potential complications resulting from the excess fluid administration.
Choice D reason
Reporting the incident to the unit manager is incorrect. Reporting the incident to the unit manager is important for organizational awareness and accountability, but the nurse's first responsibility is to assess the client's vital signs and address any potential complications.

a."OJ" for orange juice is not recommended. While it might seem straightforward, "OJ" could be confused with "oj" or other abbreviations, leading to potential confusion. It's better to write out "orange juice."

b."SS" for sliding scale is not recommended" could be misinterpreted or confused with other meanings. It's safer to write out "sliding scale."

c.SQ is commonly mistaken as “5 every”.Use SUBQ (all UPPERCASE letters, without spaces or periods between letters), or subcutaneous(ly).

d.This is a commonly accepted abbreviation in medical documentation, meaning bathroom privileges.