Exhibits Which assessment finding is most concerning and requires immediate nursing intervention?
Explanation & Rationale
A. Blood pressure of 138/84 mmHg: This is within the acceptable range for a 68-year-old adult, especially with a history of hypertension. It does not indicate an acute threat or require immediate intervention in the context of pneumonia. B. WBC count of 15,000/mm³: An elevated WBC count is expected in response to infection, such as pneumonia. While it confirms an inflammatory process, it is not the most urgent issue requiring immediate nursing action. C. Blood glucose of 198 mg/dL: This mild hyperglycemia is not uncommon in infections and stress responses, particularly in patients with diabetes. It should be monitored, but it is not an immediate danger to the patient. D. Oxygen saturation 89%: This low oxygen saturation indicates hypoxemia and impaired gas exchange, which is critical in a patient with pneumonia. Immediate oxygen therapy is necessary to prevent tissue hypoxia and respiratory failure.