A nurse is participating in the care of a client as a member of the interprofessional team. Which of the following actions should the nurse take? Select all that apply.

Rationale: A. This option is correct because all significant changes in the client’s condition, including the sudden deterioration and intubation, must be documented accurately in the EMR. Thorough documentation ensures continuity of care, legal protection, and communication among the interprofessional team. B. This option is correct because the client’s sudden deterioration and need for mechanical ventilation require immediate revision of the care plan. Updates should include new interventions, monitoring requirements, and goals relevant to the client’s current status, ensuring safe and appropriate care. C. This option is correct because a negative variance occurs when the client’s actual progress deviates from the expected outcomes outlined in the critical pathway. The client’s sudden respiratory failure represents a deviation that should be recorded to guide future care planning and quality improvement. D. This option is incorrect because the critical pathway should not be discontinued; it remains a guide for expected outcomes. Instead, variances should be documented, and the pathway adjusted as appropriate. E. This option is incorrect because the client is acutely unstable and requires ongoing intensive care. Discharge summary documentation is premature and not relevant at this point.