Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

A. Blood pressure of 136/90 mm Hg while slightly elevated, is not unusual for someone in pain or distress and does not require immediate investigation. B. Oxygen saturation 95% on room air is within the acceptable range for an adult and does not indicate immediate respiratory compromise. C. The misalignment of the collarbone indicates a possible fracture or dislocation, which requires further assessment and imaging to confirm the extent of the injury. D. A cool left arm could indicate compromised blood flow, possibly due to vascular injury from the trauma. This requires immediate investigation to prevent complications such as ischemia. E. Swelling is a sign of trauma, which may indicate soft tissue damage, fractures, or inflammation. The nurse should monitor for further signs of internal bleeding or worsening injury. F. Nausea and fatigue reported by client could suggest underlying issues such as a head injury, shock, or a systemic response to the trauma. Further evaluation is required to rule out serious complications like a concussion or other medical conditions. G. Severe pain is a critical finding that needs prompt management. Pain assessment will guide the appropriate interventions, such as pain relief and further diagnostics to identify underlying causes. H. While decreased range of motion is important, it is expected due to the trauma and pain from the fall. It will likely be addressed after the immediate concerns of injury and vascular status are managed.