During an assessment of an anxious client diagnosed with right lower lobe pneumonia, the nurse notes a new onset change in mental status and tachypnea. The latest vital signs for the client are T: 98.4 F; HR: 108; RR: 28; BP: 144/90; Pulse ox: 88%. What is the priority nursing action?

Choice A Reason
A creatinine level of 0.8 mg/dL falls within the normal range for adults, which is typically 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. This indicates normal kidney function and is not a cause for immediate intervention post-operatively.

Choice B Reason
A potassium level of 4.2 mEq/L is within the normal range, which is generally between 3.6 and 5.2 mEq/L. This level indicates a stable electrolyte balance and is not a cause for immediate concern following shoulder replacement surgery.

Choice C Reason
A white blood cell (WBC) count of 9,000 mm³ is within the normal range, which typically spans from 4,500 to 11,000 WBCs per mm³. This suggests there is no active infection or inflammation that requires immediate intervention.

Choice D Reason
A hemoglobin level of 7.1 g/dL is considered low, as the normal range for adult males is generally 13.8 to 17.2 g/dL and for adult females is 12.1 to 15.1 g/dL. Low hemoglobin can indicate anemia, which may be due to blood loss during surgery or other underlying conditions. This requires immediate intervention to address potential oxygenation issues and determine the cause of the anemia.

Choice A reason:
Cyanosis, or a bluish discoloration of the skin, particularly in the nail beds, is a sign of inadequate oxygenation and would not indicate successful intervention. The absence of cyanosis would be a positive outcome, reflecting improved oxygen saturation.

Choice B reason:
Lungs clear to auscultation would indicate that air is moving through all regions of the lungs without obstruction from fluid or mucus, which is a sign of recovery from pneumonia. This finding suggests that the interventions aimed at improving gas exchange, such as positioning, deep breathing exercises, and suctioning if needed, have been effective.

Choice C reason: The inability to speak in full sentences often indicates respiratory distress and would not be a sign of successful nursing intervention. An improvement would be the client's ability to speak in full sentences without difficulty, reflecting better lung function and gas exchange.

Choice D reason:
Pulse oximetry readings between 94-96% on room air are within normal limits and indicate adequate oxygen saturation and gas exchange. This is a clear sign that the client's respiratory status has improved, and the interventions for Impaired Gas Exchange have been successful.

Choice E reason:
Bronchovesicular breath sounds are normal breath sounds heard over the major bronchi and are typically moderate in pitch and intensity. However, they are not specifically indicative of successful intervention for Impaired Gas Exchange. The absence of abnormal sounds such as crackles or wheezes would be more relevant.