The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select the 3 actions the nurse should take.

Postoperative deterioration involving hypotension, metabolic acidosis, hypoxemia, and electrolyte imbalance suggests a rapidly worsening systemic condition that may affect perfusion, oxygenation, and cardiac stability. The ABGs show severe acidemia (pH 7.1), hypoxemia, and elevated PaCO₂, while potassium is critically elevated, increasing the risk of life-threatening dysrhythmias. The client is also showing signs of shock with altered perfusion (cool, clammy skin, delayed capillary refill, hypotension, tachycardia). Immediate nursing priorities focus on oxygen delivery, neurologic monitoring, and cardiac rhythm surveillance. Rationale: A. Obtaining an order for a soft diet is not appropriate because the client is hemodynamically unstable and demonstrating signs of respiratory and metabolic compromise. Oral intake is not a priority at this stage, and the client’s condition suggests potential need for further stabilization before any diet advancement. Nutritional progression should only be considered once airway, breathing, and circulation are stabilized. B. Monitoring for cardiac dysrhythmias is essential because the client has significant hyperkalemia (potassium 6 mEq/L) and severe acid-base imbalance. Both conditions increase myocardial irritability and risk of life-threatening arrhythmias such as ventricular tachycardia or fibrillation. Continuous ECG monitoring is critical given the presence of sinus tachycardia and worsening metabolic status. C. Monitoring the client’s level of consciousness is necessary because severe hypoxia, acidosis, and hypotension can lead to decreased cerebral perfusion and altered mental status. Early signs of neurologic decline may indicate worsening shock or respiratory failure. Frequent assessment helps detect deterioration requiring urgent intervention. D. Placing the client in a high-Fowler’s position may assist ventilation in some respiratory conditions, but it does not address the underlying instability or correct hypoperfusion. While positioning can support breathing, the client’s condition requires oxygen therapy and stabilization of circulation first. Positioning alone is insufficient for managing this level of respiratory and metabolic compromise. E. Applying oxygen is a priority because the client is hypoxemic (SpO₂ 88% on room air, PaO₂ 76 mm Hg) with signs of respiratory distress. Oxygen therapy improves tissue oxygenation and helps reduce anaerobic metabolism contributing to acidosis. This intervention is critical to support vital organ function while further treatments are initiated.