The unlicensed assistive personnel (UAP) notifies the nurse of these vital signs for a client on the medical-surgical unit: temperature 97.6°F, respirations 20, pulse 122, and BP 98/72. Which actions should the nurse do next?

Choice A reason: Decreasing fluid intake is appropriate for hypervolemia, as excess fluid exacerbates conditions like heart failure, causing edema and hypertension. Limiting fluids reduces fluid overload, preventing complications like pulmonary edema, indicating the client understands this aspect, requiring no further teaching on this point.

Choice B reason: Avoiding high-sodium foods is correct, as sodium retains water, worsening hypervolemia. Reducing sodium prevents fluid retention, lowering risks of edema and heart failure exacerbation, showing the client understands this self-management strategy, making further teaching unnecessary for this aspect of hypervolemia care.

Choice C reason: Weighing oneself weekly is inadequate for hypervolemia, as daily monitoring detects early fluid retention (2-3 pounds). Sudden weight gain signals worsening fluid overload, risking pulmonary edema. This statement indicates a need for further teaching on the importance of daily weights to manage hypervolemia effectively.

Choice D reason: Calling the physician for swelling is appropriate, as edema indicates fluid retention in hypervolemia. Prompt reporting allows early intervention to prevent complications like heart failure, showing the client understands this action, requiring no further teaching on reporting symptoms for timely medical management.

Choice A reason: Asking the UAP to reassess delays accurate assessment by a qualified nurse. Pulse 122 and BP 98/72 suggest tachycardia and hypotension, requiring professional validation and intervention, making this less appropriate than direct nurse reassessment and provider notification.

Choice B reason: Reassessing the client validates vital signs (pulse 122, BP 98/72), indicating tachycardia and hypotension, possibly from hypovolemia or sepsis. Accurate nurse assessment ensures reliable data for diagnosis, preventing complications like shock, making this a critical action in this scenario.

Choice C reason: Notifying the provider is essential, as tachycardia (pulse 122) and hypotension (BP 98/72) suggest serious conditions like hypovolemia or sepsis. Prompt reporting ensures timely interventions, such as fluids or diagnostics, preventing deterioration, making this necessary alongside reassessment.

Choice D reason: Sitting the client up may improve breathing but does not address tachycardia and hypotension, which suggest hypovolemia or other issues. These vital signs require reassessment and provider notification to diagnose and treat the cause, making positioning less urgent.