Based on the physical exam findings, which assessment indicates the client’s condition is worsening?

Choice A rationale

Cyanotic mucous membranes and oxygen saturation of 84% indicate severe hypoxemia. Normal oxygen saturation is 95–100%. The cyanosis suggests inadequate tissue oxygenation, requiring immediate intervention to prevent respiratory failure.

Choice B rationale

Diffuse wheezing and tremors may signify severe airway obstruction or beta-agonist overuse. While concerning, these findings are not as immediately life-threatening as hypoxemia and cyanosis.

Choice C rationale

Elevated blood pressure (168/90 mm Hg) and heart rate (98/min) may indicate stress or pain but do not reflect acute life-threatening changes compared to severe hypoxemia.

Choice D rationale

Clear rhinorrhea and warm, dry skin may suggest mild upper respiratory infection. These findings do not indicate imminent danger or severe respiratory compromise compared to hypoxemia and cyanosis.

Choice A rationale

Palpation after auscultation minimizes alterations in bowel sounds caused by palpation. Listening first ensures the most accurate assessment of bowel activity before external manipulation potentially disrupts peristalsis.

Choice B rationale

Listening for 5 minutes ensures accurate detection of absent bowel sounds, which require prolonged assessment to confirm. Normal bowel sounds typically occur every 5-30 seconds, necessitating extended listening before documenting absence.

Choice C rationale

Auscultating after a meal could result in increased bowel sounds due to digestion, which may not represent baseline activity. Waiting allows for a more accurate assessment of the client’s normal bowel sounds.

Choice D rationale

Shiny, taut skin on the abdomen is indicative of ascites or edema and is not an expected finding. Such documentation overlooks the need for further assessment of potential fluid accumulation.