Exhibits Click to highlight the assessment findings that require immediate follow up by the nurse. Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.

Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air. Rationale: An oxygen saturation level of 91% indicates hypoxemia, which is concerning and requires immediate intervention. Normal oxygen saturation levels should be between 95% and 100%. The nurse should assess the client further and consider supplemental oxygen or other interventions to improve oxygenation. Wheezing suggests bronchoconstriction, indicating that the client is experiencing significant respiratory distress. Given her history of asthma and the ineffectiveness of her usual albuterol dose, further assessment and potential escalation of treatment (such as systemic corticosteroids or nebulized medications) are warranted. Pallor can be a sign of decreased perfusion or oxygenation and may indicate a worsening respiratory condition. This finding requires further evaluation of vital signs and potential interventions to address the underlying cause. Tachycardia (elevated heart rate) may indicate stress or inadequate oxygenation, especially in the context of respiratory distress. The nurse should monitor the client's cardiovascular status closely and consider the need for interventions.