A nurse in the emergency department is assisting in the care of a client. Click to highlight the findings that require immediate follow-up. To deselect a finding click on the finding again. Nurses Notes 1630: Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields, Diffuse, raised rash present on trunk. Abdomen soft, nontender Vital Signs 1630: Temperature 38.3°C (101°F) Heart rate 110/min Respiratory rate 30/min Blood pressure 90/55 mmHg Oxygen saturation 91% on room air

Shortness of breath. The client is experiencing respiratory distress, which could indicate a severe allergic reaction (anaphylaxis). Immediate intervention is needed to prevent airway compromise and respiratory failure. Intercostal retractions. Retractions occur when breathing is labored, suggesting airway obstruction or bronchoconstriction. This is a sign of worsening respiratory distress, requiring urgent medical attention. Wheezing auscultated throughout lung fields. Wheezing suggests bronchospasm, which is common in anaphylaxis and asthma attacks. The presence of diffuse wheezing indicates that the airways are narrowing, making breathing more difficult. Diffuse, raised rash present on trunk. A new-onset rash following antibiotic administration raises suspicion for anaphylaxis or a severe allergic reaction. Immediate treatment with antihistamines and corticosteroids may be required. Respiratory rate 30/min. The increased respiratory rate indicates that the client is compensating for airway constriction and hypoxia. This is an early warning sign of impending respiratory failure if not treated promptly. Blood pressure 90/55 mmHg. The drop in blood pressure suggests anaphylactic shock, where vasodilation and fluid leakage from capillaries lead to hypotension. Immediate administration of epinephrine is necessary to prevent cardiovascular collapse. Oxygen saturation 91% on room air. A decrease in oxygen saturation indicates impaired gas exchange, likely due to airway swelling and bronchospasm. Supplemental oxygen therapy should be provided to prevent further desaturation.