The unlicensed assistive personnel reports vital signs for a patient to the nurse: Oral Temperature of 99.2 degrees Fahrenheit. Radial pulse of 88 bpm and regular, Respirations of 18 bpm and regular, blood pressure supine in left arm of 178/112 mm Hg. and oxygen saturation of 95% on room air. Which vital sign should the nurse be most concerned about?

A. Make sure the bed is low, locked, and the call light is in reach of the patient:

This action is crucial for preventing falls. A low bed reduces the risk of injury if the client were to accidentally fall. Locking the bed prevents unintended movement, and ensuring the call light is within reach allows the client to call for assistance if needed.

B. Ask the client if they have ordered their dinner:

While nutrition is important, it is not the immediate priority after assisting the client back to bed. Safety measures should be addressed first.

C. Educate the client on the surgical procedure they are scheduled for in the morning:

While pre-operative education is important, it is not the immediate concern after assisting the client back to bed. Safety measures for the current situation take precedence.

D. Check that the client is wearing non-skid socks while in bed:

While wearing non-skid socks is a safety measure, ensuring the bed is low, locked, and the call light is accessible is a more immediate and critical action after assisting the client back to bed.

A. Use standard precautions in caring for all clients:

Standard precautions involve applying infection prevention practices to all clients, regardless of their known or suspected infectious status. This includes hand hygiene, use of personal protective equipment (PPE), and safe injection practices. Standard precautions are designed to prevent the transmission of microorganisms and break the chain of infection.

B. Place all post-surgical clients in contact isolation:

Contact isolation is typically used for clients with known or suspected infections that can be spread through direct or indirect contact. Placing all post-surgical clients in contact isolation may not be necessary unless there is evidence of a specific infectious condition.

C. Order IV antibiotics for all clients with sacral pressure wounds:

Ordering antibiotics is a specific treatment for bacterial infections but does not address the broader approach of breaking the chain of infection for all clients.

D. Limit visitations to 2 people a day for each client:

While limiting visitations can reduce the risk of introducing infections, it does not address the nurse's direct care practices and adherence to infection prevention measures.