The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data. Complete the following sentence by using the list of options. The nurse should first plan to dropdownand thendropdown.

Rationale for correct choices • Contact the provider for an antibiotic prescription: The client exhibits signs of infection at the surgical site, including warmth, tenderness, thick yellow discharge, fever, and hypotension, which suggest sepsis or worsening infection. Prompt provider notification ensures timely initiation of antibiotics to treat the underlying infection and prevent further complications. • Dim the lights: Reducing environmental stimuli helps minimize sensory overload, which can exacerbate confusion, hallucinations, and agitation in older adults experiencing delirium. Dimming lights creates a calmer, safer environment and supports reorientation and comfort while the underlying infection is being managed. Rationale for incorrect choices • Ask the client's partner to leave the room: Removing the partner may increase the client’s confusion and agitation. Familiar caregivers provide comfort and help with reorientation, particularly in delirious or disoriented older adults. Keeping supportive family present is recommended unless safety concerns exist. • Increase the volume on the television: Amplifying auditory stimuli can worsen confusion and agitation in a client with delirium. Older adults with hearing impairments may misinterpret sounds, increasing hallucinations or distress. Calmer, quieter environments are more appropriate. • Assist with elimination: While monitoring elimination is important for overall care, it is not the immediate priority. The client’s acute delirium and potential infection pose a greater immediate risk. Addressing underlying infection and reducing sensory stress takes precedence. • Place the client in 4-point restraints: Restraints are a last-resort intervention due to risks of injury, further agitation, and loss of dignity. Non-pharmacologic measures and addressing the underlying cause (infection) are preferred first. Restraints may be considered only if the client’s safety is at imminent risk and other measures fail.