An adult male is transferred from post anesthesia care unit (PACU) to the postoperative unit following an internal fixation of a fractured tibia and fibula that occurred during a motor vehicle collision (MVC). The nurse reports that the client received morphine 2 mg intravenously 45 minutes ago and is currently experiencing pain relief of 7 from a previous report of 10. Postoperative prescriptions include, start patient-controlled analgesia (PCA) using hydromorphone 0.2 mg on demand and 0.2 mg/hour basal rate. Which client information should the nurse provide to complete this report?

Choice A reason: This is the most urgent situation, as the client may have uremic encephalopathy, a serious complication of acute kidney injury that affects the brain function. The nurse should assess the client's neurological status, check the serum electrolytes and blood urea nitrogen (BUN) levels, and notify the provider immediately.

Choice B reason: This is a concerning situation, as the client may have a fever due to an infection or a reaction to the enteral feeding. The nurse should monitor the client's vital signs, check the feeding tube for patency and placement, and obtain a blood culture if ordered.

Choice C reason: This is a significant situation, as the client may have dehydration, electrolyte imbalance, and organ damage due to the heat stroke. The nurse should monitor the client's fluid intake and output, check the serum electrolytes and creatinine levels, and provide cooling measures as needed.

Choice D reason: This is a relevant situation, as the client may have dehydration, electrolyte imbalance, and nutritional deficiency due to the hyperemesis gravidarum. The nurse should monitor the client's fluid intake and output, check the serum electrolytes and glucose levels, and provide antiemetic medication as prescribed.

Choice A reason: This is the best intervention to ensure the safety of the clients and staff. According to the [hospital fire drill requirements](^3^), the first step in a fire evacuation is to rescue persons from the room or area and move them away from where fire, smoke, or the strong smell of smoke exists. Ambulatory clients can be assisted to the nearest fire exits by the nursing staff, following the [fire safety standard operating procedure](^2^).

Choice B reason: This is not a good intervention, as it may delay the evacuation and endanger the clients and staff. Wheelchairs are not designed to be used in fire situations, and they may not fit through the fire exits or the stairwells. Non-ambulatory clients should be transferred using evacuation devices such as evacuation chairs, stretchers, or mattresses, as recommended by the [hospital evacuation checklist](^5^).

Choice C reason: This is a dangerous intervention, as it may expose the visitors to the fire and smoke. Service elevators should not be used in a fire situation, as they may malfunction or stop at the fire floor. Visitors should be instructed to use the fire exits and the stairwells to evacuate the building, following the [fire safety standard operating procedure](^2^).

Choice D reason: This is a passive intervention, as it does not ensure the safety of the clients and staff. Shutting the doors to the client rooms may help to contain the fire and smoke, but it does not guarantee that they will not spread to other areas. The charge nurse should initiate the evacuation procedures as soon as possible, following the [hospital evacuation checklist](^5^).