Question

a nurse is caring for a client on a medical surgical unit.
exhibit 1
exhibit 2
exhibit 3
exhibit 4
vital signs
day 1, 1800:
temperature 39.3° c (102.8° f)
heart rate 102/min
respiratory rate 24/min
blood pressure 144/88 mm hg
oxygen saturation 97% on room air
day 1, 2200:
temperature 39.3° c (102.8° f)
heart rate 90/min
respiratory rate 14/min
blood pressure 134/80 mm hg
oxygen saturation 96% on room air
day 2, 0600:
heart rate 110/min
respiratory rate 28/min
blood pressure 80/46 mm hg
oxygen saturation 88% on room air
complete the following sentence by using the lists of options.
the nurse should fir select...
select...
measure temperature
establish an open airway
review the client’s medical record for allergies
perform a mental status assessment
administer a medication to increase blood pressure

Explanation:

The client's blood pressure is 80/46 mm Hg (hypotensive) and oxygen saturation is 88% (low), but the first action when addressing a client's care, especially before interventions, should be to check for allergies if medications (like for blood pressure) are to be administered. However, looking at the vital signs progression, at Day 2, 0600, the client has hypotension and respiratory changes. But the options: "establish an open airway" is for airway issues (not immediate here as O2 sat is 88% but not airway obstruction), "measure temperature" – temp was already 39.3 earlier, "review allergies" is pre - medication, but the most urgent? Wait, no, the first action when starting care or before giving meds. But the client's current status at the time of action (maybe before administering a med to increase BP) – so first, review medical record for allergies to ensure safe administration. Wait, but the vital signs at Day 2, 0600 show hypotension (80/46) and tachypnea (28), hypoxia (88% on room air). But the options: "administer a medication to increase blood pressure" – but first, check allergies. Wait, maybe the question is about the first action when preparing to administer a med. So the correct option is "review the client's medical record for allergies" as it's a safety measure before giving any medication, including one to increase BP.

Answer:

review the client's medical record for allergies