A nurse is caring for a client on a medical surgical unit. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The nurse should first follow up on the client's dropdown and dropdown
Explanation & Rationale
Rationale for Correct Choices Oxygen saturation: The client’s oxygen saturation dropped from 95% to 90% on 1 L/min nasal cannula, indicating potential hypoxemia. Immediate assessment and intervention are required to prevent respiratory compromise. Behavioral findings: The client’s agitation and verbal report of “I feel like something is wrong” signal a possible early change in condition. Behavioral changes can precede vital sign abnormalities and should be promptly evaluated alongside physiological measures. Rationale for Incorrect Choices Pain: While pain is reported at a moderate level, it is expected postoperatively and does not explain the sudden change in oxygen saturation or agitation. Pain should be addressed after assessing potential acute complications. WBC count: A slightly elevated WBC may reflect postoperative inflammation or infection but is not the immediate priority in the context of acute hypoxemia. Bowel findings: Hypoactive bowel sounds are typical after abdominal surgery due to anesthesia and are not an urgent concern compared with declining oxygenation and agitation.