A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

A. A client who developed a pressure ulcer on the sacrum: The development of a pressure ulcer during hospitalization is considered a preventable adverse event and requires an incident report. It reflects a potential lapse in standard care practices related to skin integrity and client repositioning.

B. A client who refused to take a prescribed stool softener: Clients have the right to refuse medications. This occurrence should be documented in the medical record, but it does not require an incident report since it is an exercise of client autonomy.

C. A client who reported feeling dizzy while ambulating: Feeling dizzy during ambulation should be documented and addressed with safety measures, but if no fall or injury occurred, it typically does not necessitate a formal incident report.

D. A client who received medication 1 hr after it was due: A slight delay in medication administration may need to be documented depending on the medication's importance, but a 1-hour delay, unless involving critical medication like insulin or anticoagulants, usually does not require a formal incident report.

A. Hyperglycemia: Albuterol is not prescribed to manage blood glucose levels. While it can sometimes cause a mild increase in blood glucose as a side effect, its primary therapeutic action is not directed at treating hyperglycemia or any diabetic conditions.

B. Swelling of the lips: Swelling of the lips could indicate an allergic reaction or angioedema, which is a medical emergency. Albuterol is not used to treat allergic swelling; epinephrine would be the medication of choice in managing severe allergic reactions or anaphylaxis.

C. Nausea: Albuterol is not intended to treat nausea. Although gastrointestinal upset, including nausea, can sometimes occur as a side effect of albuterol, it is not administered for the purpose of controlling nausea in clients.

D. Shortness of breath: Albuterol is a short-acting beta2-agonist that works by relaxing bronchial smooth muscle, leading to bronchodilation. It is commonly prescribed to relieve acute episodes of shortness of breath, wheezing, or bronchospasm, particularly in asthma or COPD.