When a client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system?

A. Ask the client to perform IS: Encouraging incentive spirometry promotes lung expansion and prevents atelectasis, but it is an intervention rather than an assessment. Performing this action without first gathering additional clinical data does not provide information about the underlying cause of the increased respiratory rate or the client’s oxygenation status.

B. Notify the provider: Notifying the provider is a critical step when a patient’s condition may be deteriorating, but it occurs after the nurse has collected and interpreted objective data. Immediate reporting without first assessing vital signs and oxygenation may result in incomplete communication and delay targeted interventions.

C. Obtain vitals and pulse ox: Gathering vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation, allows the nurse to quantify the client’s current status and identify potential hypoxia, infection, or other causes of tachypnea. This reflects both data collection and clinical reasoning, forming the basis for prioritizing further interventions and communicating effectively with the provider.

D. Call rapid response: Activating the rapid response team is appropriate for signs of acute deterioration, but an increased respiratory rate of 24 alone may not meet criteria for immediate team activation. The nurse should first gather additional assessment data to determine the severity of the situation and the appropriate level of intervention.

A. Client who urinates frequently due to diuretic therapy: Increased urination may lead to fluid loss and potential dehydration if not managed, which can affect skin turgor and perfusion. However, with adequate fluid replacement, this factor alone does not significantly impair the physiological processes required for wound healing.

B. Client with limited mobility recovering from knee surgery: Limited mobility can increase the risk of pressure injuries due to prolonged pressure over bony prominences and reduced circulation. While this may contribute to delayed healing if a wound develops, it does not inherently impair systemic healing processes as chronic metabolic and vascular conditions.

C. Client who is NPO one day before abdominal surgery: Short-term NPO status typically does not result in significant nutritional deficiency or impair wound healing. The body’s nutrient stores and perioperative management generally compensate for this brief period without oral intake, making it a minimal risk factor.

D. Client with diabetes, obesity and current cigarette smoker: Diabetes impairs wound healing through microvascular damage, reduced tissue perfusion, and impaired leukocyte function, increasing infection risk. Obesity decreases vascularity of adipose tissue and places mechanical stress on wounds, while smoking causes vasoconstriction and reduces oxygen delivery due to carbon monoxide exposure. These factors significantly disrupt all phases of wound healing.