A nurse is caring for a client on a medical-surgical unit. Exhibits Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect a finding, click on the finding again. 0830 Client assessment performed. Heart rate 102/min Respiratory rate 20/min Breath sounds clear and equal bilaterally Blood pressure 128/66 mm Hg Temperature 38.9°C (102°F) Oxygen saturation 95% on room air Abdomen soft, nondistended with hyperactive bowel sounds audible in 4 quadrants. Hematocrit 47% (37% to 47%) Hemoglobin 16 g/dL (12 g/dL to 16 g/dL) Potassium 3.3 mEq/L (3.5 to 5.0 mEq/L)

Rationale for correct choices: Heart rate 102/min: Tachycardia may indicate dehydration from diarrhea, fever, or early sepsis. The nurse should monitor trends, assess for other signs of fluid deficit, and notify the provider if it worsens. Temperature 38.9°C (102°F): Fever indicates infection, consistent with C. difficile. This requires monitoring, infection control measures, and potential initiation or adjustment of antibiotic therapy as prescribed. Hyperactive bowel sounds: Increased bowel activity reflects ongoing diarrhea and gastrointestinal irritation from the infection. Monitoring bowel frequency and character helps assess severity and guides fluid and electrolyte replacement. Potassium 3.3 mEq/L: Hypokalemia is a significant electrolyte disturbance caused by diarrhea. It increases the risk for cardiac dysrhythmias, muscle weakness, and requires prompt intervention such as potassium replacement and provider notification. Rationale for incorrect choices: Abdomen soft, nondistended: While the client has diarrhea, a soft, nondistended abdomen is a normal finding and does not require immediate corrective action. Hematocrit 47% / Hemoglobin 16 g/dL: These values are at the upper normal limits but do not indicate acute problems and do not require immediate follow-up.