The nurse reviews the entries in the medical record.

Admission Assessment 0900:
Client reports, "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current medications:

Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:

General: client appears uncomfortable, diaphoretic

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)

The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client.
Nursing Actions

A. "Try using an abdominal support belt." - An abdominal support belt is recommended to provide support to the growing abdomen and can help alleviate backaches that are common during pregnancy.

B. "Take hot showers to help relieve itching." - This statement is incorrect. Hot showers can actually worsen itching and dry out the skin. Lukewarm showers are recommended instead.

C. "Wear loose-fitting clothing." - This statement is correct. Loose-fitting clothing can provide comfort and reduce irritation, especially in areas experiencing itching.

D. "Wear flat or low-heeled shoes." - This statement is correct. Flat or low-heeled shoes provide better support and stability during pregnancy, reducing the risk of falls.

E. "You can douche twice weekly." - This statement is incorrect. Douching is not recommended during pregnancy as it can disrupt the natural balance of vaginal flora and increase the risk of infections.

F. "Eat two large meals a day." - This statement is incorrect. Eating large meals can lead to discomfort and heartburn. It is better to eat frequent smaller meals throughout the day during pregnancy.

G. "You should avoid fried foods." - This statement is correct. Fried foods can exacerbate heartburn and should be avoided to reduce discomfort.

Among the given assessment findings, the one that warrants the most immediate intervention by the nurse is the shortness of breath on exertion. Shortness of breath on exertion in a client with a history of chronic obstructive pulmonary disease (COPD) and pneumonia indicates increased respiratory distress and compromised lung function. It suggests that the client is experiencing difficulty breathing even with minimal physical exertion. This finding may indicate worsening respiratory status, increased oxygen demand, and inadequate oxygenation. The nurse should take immediate action to address the shortness of breath, which may involve providing supplemental oxygen, initiating or adjusting bronchodilator medications, and monitoring the client's respiratory status closely. Prompt intervention is crucial to ensure adequate oxygenation and prevent respiratory failure.

While the other assessment findings (bilateral diffuse wheezing, temperature of 100.5 °F, and yellow expectorated sputum) are also important and require attention, the shortness of breath on exertion poses the greatest immediate risk and necessitates immediate intervention to address the client's respiratory distress.