Name: Patricia Smithe Provider: M. Pike, MD Code Status: Full Code Allergies: None known Age: 74 years Weight: 66.48 kg Review the electronic health record. Which vital sign(s) should the nurse find concerning? Select all that apply. Blood Pressure 90/58 Oxygen Saturation 97% on room air Pain 1/10 right leg Temperature 98.9 F(37.1 C) Heart Rate 118

A. The respiratory rate is not provided in the assessment data. Because no abnormal value is documented, respirations cannot be identified as concerning based on the available information. There is no evidence of tachypnea, bradypnea, or respiratory distress. B. A blood pressure of 90/58 mmHg is hypotensive. In a 74-year-old client, hypotension is especially concerning because it may indicate decreased organ perfusion. Potential causes include dehydration, blood loss, sepsis, medication effects, or cardiac dysfunction. Older adults have decreased physiologic reserve, so low blood pressure increases the risk for dizziness, falls, syncope, kidney injury, and altered mental status. This finding requires immediate assessment. C. A pain rating of 1/10 indicates minimal discomfort. This level of pain is mild and not physiologically destabilizing. It does not suggest acute distress or hemodynamic compromise and therefore is not a priority concern. D. A heart rate of 118 beats per minute is tachycardia. Normal adult heart rate ranges from 60 to 100 beats per minute. Tachycardia in this context is concerning, especially when paired with hypotension. The elevated heart rate may represent a compensatory mechanism in response to low blood pressure in an attempt to maintain cardiac output and organ perfusion. This combination raises concern for early shock, hypovolemia, or other circulatory instability and requires prompt follow-up. E. A temperature of 98.9°F (37.1°C) is within normal limits. There is no evidence of fever or hypothermia. This value does not indicate infection or systemic instability. F. An oxygen saturation of 97% on room air is normal and indicates adequate oxygenation. There is no sign of hypoxia or respiratory compromise.