A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

A. Prealbumin levels are often used as a marker of nutritional status and can indicate protein deficiency. A low prealbumin level may suggest malnutrition or inadequate protein intake. However, the prealbumin level of 25 mg/dL is within the normal range (normal range typically 15-35 mg/dL), so it does not require immediate reporting to the provider.
B. The client's temperature of 37.6°C (99.7°F) is slightly elevated but is not indicative of a fever (typically defined as ≥38°C or 100.4°F). This finding may suggest a mild increase in body temperature, which could be related to various factors such as dehydration, infection, or environmental factors. Since it's only slightly elevated and within a

borderline range, it may not require immediate reporting unless other concerning symptoms are present.
C. Urine specific gravity measures the concentration of solutes in the urine and can indicate hydration status. A specific gravity of 1.035 is considered high and may suggest concentrated urine, which could be a sign of dehydration or renal dysfunction. Therefore, this finding should be reported to the provider for further evaluation.
D. Hypoactive bowel sounds indicate decreased or absent bowel motility and can be a sign of gastrointestinal dysfunction, such as ileus or obstruction. While it's important to monitor bowel sounds and report any significant changes to the provider, hypoactive bowel sounds alone may not always require immediate reporting unless other concerning symptoms are present.

A. The Sims position is a lateral position used for procedures such as rectal examinations and enemas and is not typically indicated for managing increased intracranial pressure.
B. The supine position may worsen increased intracranial pressure by increasing venous return and intracranial pressure.
C. The left lateral position may be used in specific circumstances, such as to relieve pressure on the vena cava in pregnancy, but it is not typically indicated for managing increased intracranial pressure.
D. Positioning the client in Low-Fowler's position (with the head of the bed elevated approximately 15-30 degrees) helps facilitate venous drainage from the brain, thereby reducing intracranial pressure. This position promotes optimal cerebral perfusion and helps manage increased intracranial pressure.