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

A. Develop a plan for the client to integrate the change into her lifestyle: Developing a plan for integrating change into one's lifestyle is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the focus is on considering change rather than developing a detailed plan.
B. Assist the client in setting goals to make the change: Setting specific goals is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the client is not yet ready to commit to specific goals.
C. Recommend small changes for the client to make to change her behavior over time: During the contemplation stage of health behavior change, clients are considering making a change but are not yet committed to taking immediate action. This is also more suitable for the preparation or action stages.
D. In the contemplation stage, the client is aware of the problem and is considering making a change but has not yet committed to action. Providing information about the benefits can help the client move toward the next stage of change.

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.