An older client's spouse reports to the nurse that there has been a behavior change in the client for the past several days. The client was recently seen by the healthcare provider at the clinic and was treated for seasonal allergies and insomnia. Which action is most important for the nurse to implement?

A. Perform pulmonary function test
This is important for assessing lung function, but it is not an immediate priority during an acute exacerbation when the patient's oxygen saturation is low and they are experiencing respiratory distress.
Pulmonary function testing can be done once the patient's acute symptoms are stabilized.
B. Measure vital signs
While vital signs are important for ongoing assessment, the patient's vital signs were already assessed at admission and are being monitored every 4 hours as per orders.
Administering oxygen and albuterol to stabilize the patient's condition takes precedence over routine vital sign checks immediately after the initial assessment.
C. Provide a regular diet tray
This is a routine aspect of care and does not address the acute respiratory distress or hypoxemia that require immediate attention.
It can be done once the patient's respiratory status has stabilized.
D. Give albuterol as ordered
The patient is experiencing an asthma exacerbation with wheezing and subcostal retractions. Albuterol is a bronchodilator that helps relieve bronchospasm and improve airflow.
It was ordered for nebulization now and every 4 hours PRN (as needed) for wheezing.
Administering albuterol promptly is crucial to help alleviate respiratory distress and improve lung function.
E. Apply oxygen 1 L/minute
The patient's oxygen saturation is 91% on room air, which is below the target of greater than 94%. Oxygen therapy is indicated to correct hypoxemia and improve oxygen saturation.
The order specifies to titrate oxygen to keep saturation greater than 94%, starting at 1 L/minute via nasal cannula.

At risk of hypovolemia

D. Total blood loss of 800 mL

A total blood loss of 800 mL indicates significant hemorrhage, which puts the client at risk for hypovolemia (low blood volume). While exact definitions may vary, typically, blood loss exceeding 500 mL postpartum is considered significant and increases the risk of hypovolemia if not managed appropriately.

F. 200 mL blood loss

While 200 mL of blood loss is within the normal range for immediate postpartum period, it still represents a loss of blood that, if ongoing, could potentially lead to hypovolemia if not monitored closely.

Condition has improved

A. Fundus massaged until firm and at umbilicus

Massaging the fundus until it is firm and at the umbilicus helps ensure uterine contraction, which reduces the risk of excessive bleeding and promotes hemostasis. This indicates that uterine tone is adequate, which is a positive sign.

C. Straight catheter produced 500 mL clear yellow urine

The passage of 500 mL of clear yellow urine indicates adequate renal perfusion and hydration status, suggesting that the client's fluid balance is being maintained or improved, which is important in preventing hypovolemia.

E. Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air

Stable vital signs with normal blood pressure, heart rate, and oxygen saturation indicate adequate perfusion and oxygenation. This suggests that the client's condition is stable and not immediately at risk for hypovolemia.

G. Fundus remains firm with slight lochia noted on pad

A firm fundus with slight lochia (postpartum vaginal discharge) indicates ongoing normal involution (shrinking) of the uterus with minimal bleeding. This suggests that the client's uterus is contracting well, which is favorable for preventing hypovolemia.