A nurse is caring for a patient who has cirrhosis of the liver.
The patient’s vital signs are as follows: Heart rate 101/min, Temperature 36 C (96.9 F), Respiratory rate 24/min, Blood pressure 82/58 mm Hg, Oxygen saturation 92%. Which of the following assessment findings require immediate follow-up? Select all that apply.

Choice A rationale

MRSA, or Methicillin-resistant Staphylococcus aureus, is a type of bacteria that is resistant to many antibiotics. Antiviral medications are used to treat viral infections, not bacterial infections like MRSA1234.

Choice B rationale

Patients with MRSA are typically placed on contact precautions, not airborne precautions. This is because MRSA is primarily spread through direct contact with an infected wound or from contaminated hands, not through the air.

Choice C rationale

While MRSA can survive on hands, it typically survives for less than an hour. However, the exact duration can vary depending on the conditions.

Choice D rationale

Bathing patients with water and chlorhexidine gluconate is a common practice to help control MRSA. Chlorhexidine gluconate is an antiseptic that kills a wide range of bacteria, including MRSA1234.

Choice A rationale

The patient’s blood pressure is significantly low, which could indicate hypotension, a serious side effect of epidural analgesia. This should be the nurse’s priority as it can lead to complications such as decreased perfusion to vital organs.

Choice B rationale

Lower extremity weakness can be a side effect of epidural analgesia, but it is not as immediately life-threatening as hypotension.

Choice C rationale

A slight increase in temperature may not be an immediate concern unless it continues to rise or is accompanied by other signs of infection.

Choice D rationale

Severe itching can be a side effect of epidural analgesia, but it is not as immediately life- threatening as hypotension.