The nurse has reviewed the Vital Signs at 1000.

Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

A. Potassium: The client’s potassium level is 4.1 mEq/L, which is within the normal range of 3.5–5 mEq/L. No immediate intervention is required, so this value does not need to be reported.

B. Hematocrit: The client’s hematocrit is 44%, which falls within the normal reference range of 37–47% for adults. This level is not clinically concerning and does not require reporting.

C. Sodium: The client’s sodium level is 140 mEq/L, which is within the normal range of 136–145 mEq/L. This electrolyte level is stable and does not require provider notification.

D. AST: The client’s AST is 42 U/L, slightly above the reference range of 0–35 U/L. Elevated AST may indicate hepatocellular injury or inflammation, possibly related to gallbladder disease or liver involvement, and should be reported for further evaluation.

E. WBC count: The client’s WBC count is 15,100/mm³, which is above the normal range of 5,000–10,000/mm³. Leukocytosis can indicate infection or inflammation, consistent with the client’s abdominal pain and possible biliary or gastrointestinal pathology, and requires provider notification.

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.