A nurse is caring for a postpartum client in an outpatient setting.

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

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evidenced by the client's

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A. While monitoring blood pressure is essential in the overall assessment of a patient, the given blood pressure readings (112/88 mm Hg) are within the normal range. Hence, further evaluation of blood pressure may not be immediately necessary based on the provided information.
B. A temperature of 38.1°C (100.5°F) indicates fever, which can be a sign of infection or inflammatory process. Further evaluation is warranted to determine the cause of the fever and initiate appropriate treatment.
C. The heart rate of 98/min falls within the normal range for adults (60-100 beats per minute). Although heart rate abnormalities can indicate various conditions, the given heart rate alone may not warrant immediate further evaluation without additional concerning symptoms or clinical context.
D. The oxygen saturation of 98% on room air is within the normal range (>95%).

While assessing oxygen saturation is crucial, the provided value does not indicate immediate concern. Further evaluation may be needed if the patient shows signs of respiratory distress or if there is clinical suspicion of hypoxemia.

E. Recent travel to South Africa raises concerns about potential exposure to infectious diseases endemic to that region. Further evaluation is necessary to assess for travel- related illnesses or infections, such as tuberculosis or other tropical diseases.
F. A significant weight loss of 2.26 kg (5 lb) over the last week is concerning and requires further investigation. Unintentional weight loss can be indicative of various underlying medical conditions, including infections, malignancies, or metabolic disorders.
G. The report of "blood-tinged sputum" suggests hemoptysis, which can be a sign of serious underlying conditions such as pulmonary infections, pulmonary embolism, or malignancy. Further evaluation is necessary to determine the cause and initiate appropriate management.
H. The presence of a persistent cough, especially when associated with other symptoms like fatigue, night sweats, and weight loss, raises concerns for underlying respiratory or systemic conditions. Further assessment is needed to identify the cause of the cough and provide appropriate treatment.

A. While documentation of sensitive material may be a responsibility of the charge nurse, it does not directly relate to educating a newly licensed nurse about the facility's computerized documentation system.
B. Securing client information through measures like installing a firewall is crucial in a computerized documentation system to maintain confidentiality and prevent unauthorized access or data breaches.
C. While password change frequency is an important aspect of maintaining system security, it is not the most critical information to convey to a newly licensed nurse regarding the documentation system.Most facilities require more frequent password changes to enhance security, such as every 60 to 90 days, to mitigate the risk of unauthorized access and potential breaches.
D. Providing access to all client records would violate privacy and security protocols and is not an accurate representation of how the documentation system operates.