Patient Data Exhibits Review H and P and nurse's notes. Click to highlight which assessment finding(s) should the nurse attend to right away? Admitted client. Vital signs Temperature: 96.9° F (36.1° C) internal probe via urinary catheter Heart rate: 128 beats/minute, sinus tachycardia (ST) Respirations: 14 breaths/minute Patient Data Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2) The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a PIV line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members. The client opens her eyes to verbal stimuli and follows verbal commands.

Rationale for correct choices • Heart rate 128 beats/minute, sinus tachycardia: Tachycardia signals early compensatory response to hypovolemia or hemorrhagic shock, common with abdominal trauma. Immediate attention is needed to prevent cardiovascular collapse. • Blood pressure 90/79 mm Hg, pulse pressure less than 40 mm Hg: A narrow pulse pressure with low systolic BP suggests inadequate stroke volume and poor perfusion, consistent with ongoing internal bleeding. • Capillary refill 6 seconds: Prolonged refill indicates impaired peripheral perfusion and circulatory compromise, reinforcing concerns of shock. • No urine output: Absence of urine is a critical marker of inadequate renal perfusion and systemic hypoperfusion, reflecting worsening shock status. Rationale for incorrect choices • Temperature 96.9° F (36.1° C): Slightly low but not critical; mild hypothermia is common post-trauma and can be managed after stabilizing perfusion. • Surgical dressing clean/dry with ecchymosis: Ecchymosis is expected after trauma and surgery, requiring monitoring but not immediate intervention. • Heart sounds regular, lung sounds clear: No acute cardiopulmonary decompensation detected.