The nurse is caring for a client who reports frequent nausea and vomiting for the past 24 hours. Which assessment finding requires further action by the nurse?

Choice A reason: Pale yellow urine is generally within normal limits and indicates adequate hydration. This finding does not suggest a complication requiring immediate action. Choice B reason: An oral temperature of 99 F (37.2 C) is considered a low-grade or normal temperature. It does not indicate infection or dehydration that would require urgent intervention. Choice C reason: Moist mucous membranes suggest that the client’s hydration status is currently adequate. This assessment does not raise immediate concern despite ongoing nausea and vomiting. Choice D reason: A blood pressure of 90/49 mmHg indicates hypotension, which may result from fluid loss due to persistent vomiting. Hypotension is a sign of potential hypovolemic shock or severe dehydration, requiring prompt nursing assessment and intervention to prevent complications such as organ hypoperfusion or syncope.