A nurse is caring for a client on a medical-surgical unit. Exhibits Nurses Notes 0800: Client is admitted with a 3-day history of abdominal cramps and diarrhea of 4 to 5 liquid stools/day. Client was taking PO amoxicillin/clavulanate for a respiratory tract infection, 500 mg q12h for 10 days. Antibiotics completed 7 days ago. Bilateral breath sounds clear and present throughout. Abdomen soft, nondistended with hyperactive bowel sounds audible in 4 quadrants Stool contains mucous and is foul-smelling. Stool sent for culture. Click to highlight the documentation in the client's medical record that requires further action by the nurse. Temperature 38.9° C (102°F) Blood pressure 118/56 mm Hg Heart rate 102/min Respirations 20/min Oxygen saturation 95% on room air Hermatocrit 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) Stool culture positive for Clostridium difficile (negative)

Rationale for Correct Findings: Temperature 38.9° C (102°F): A high-grade fever indicates a possible systemic infection and may require antipyretic treatment and further investigation for sepsis. Blood pressure 118/56 mm Hg: The low diastolic pressure can be a sign of early hypovolemia or systemic vasodilation, especially concerning in a client with ongoing fluid loss and infection. Potassium 3.3 mEq/L (3.5 to 5.0 mEq/L): Mild hypokalemia from diarrhea can impair cardiac and muscular function. It should be corrected promptly to prevent complications. Stool culture positive for Clostridium difficile: A positive result confirms C. difficile infection. The nurse must initiate contact precautions and notify the provider for appropriate antimicrobial therapy. Heart rate 102/min: Slight tachycardia is consistent with fever and fluid loss and is a response to a severe gastrointestinal infection like C. diff. Hence a systemic sign of inflammation and infection. Rationale for Not Highlighting Other Findings: Respirations 20/min and Oxygen saturation 95% on room air: Both respiration and oxygen saturation are within normal limits and do not suggest respiratory compromise at this time. Hematocrit 47% and Hemoglobin 16 g/dL: These values are on the upperlimit of normal, elevated but likely due to hemoconcentration from diarrhea. These are not critically abnormal and don’t require urgent intervention unless fluid status worsens.