Patient Data 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.

Mild subcostal retractions: Subcostal retractions indicate that the muscles between the ribs are pulling inward during breathing. This is a sign of increased work of breathing and can indicate respiratory distress. Wheezes noted throughout the lung fields: Wheezing is a high-pitched whistling sound produced during breathing, typically due to narrowed airways. It indicates airway obstruction, common in asthma exacerbations. Client is pale: Pallor (pale skin) can indicate reduced oxygenation or perfusion to the tissues, which can occur during respiratory distress. Heart rate of 122 beats/minute: Tachycardia (elevated heart rate) is a compensatory mechanism in response to decreased oxygen levels or increased respiratory effort. Oxygen saturation 91% on room air: Oxygen saturation below 94% indicates hypoxemia (low blood oxygen levels), which is a critical finding requiring prompt intervention.