An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 101° F (38.3° C), heart rate 130 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 100/50 mmHg Which intervention is most important for the nurse to include in the client's plan of care?

A. Measure pulse and blood pressure:
This action is crucial to assess the client's cardiovascular status. Weakness and jitteriness can be related to changes in blood pressure or cardiac function. Measuring pulse and blood pressure helps determine the client's hemodynamic stability.

B. Document anxiety on the surgical checklist:
While anxiety is a valid consideration, addressing the physiological aspects of the client's symptoms takes precedence.

C. Assess skin temperature and moisture:
Assessing skin temperature and moisture provides information about the client's perfusion and hydration status. Changes in skin characteristics can be indicative of underlying issues, and in a diabetic patient, it's important to monitor for potential complications affecting skin integrity.

D. Check fingerstick glucose level:
Given the client's recent diagnosis of type 2 diabetes mellitus and the reported symptoms of weakness and jitteriness, checking the fingerstick glucose level is crucial. Fluctuations in blood glucose levels, whether hyperglycemia or hypoglycemia, can contribute to these symptoms. This test provides immediate information about the client's glycemic status.

E. Administer a PRN dose of regular insulin:
If the fingerstick glucose level indicates hyperglycemia and the healthcare provider has prescribed a PRN (as needed) dose of regular insulin for high blood sugar, administering insulin may be necessary to address hyperglycemia promptly. This is in line with diabetes management protocols, and the nurse should follow specific orders and guidelines for insulin administration.

A. Reduced pain in eczematous areas:
While hydration of the skin may contribute to reduced pain in some cases, the primary goal of urea cream is to moisturize and hydrate the skin rather than directly address pain.

B. Healing with a return to normal skin appearance:
Urea cream can contribute to the healing process by hydrating the skin and promoting the removal of dry, scaly skin. However, complete healing and a return to normal skin appearance may also depend on the underlying cause of eczema and other factors.

C. Decreased weeping of ulcerations in affected areas:
Urea cream can help reduce excessive dryness and weeping in eczematous areas by promoting hydration and moisture balance. However, it may not directly address ulcerations, and other interventions may be needed for open wounds.

D. Hydration of affected dry skin areas:
This is the correct answer. Urea is a natural moisturizing factor that helps retain water in the skin. Applying urea cream to affected dry skin areas is expected to hydrate the skin, reduce dryness, and improve the overall moisture balance.