The patient's meal has been delivered, the nurse checks the patient's pre-meal blood sugar, and the result is 243 mg/dL. The patient is awake, alert, hungry, and able to swallow.
The next step the nurse should take is:

Choice A rationale

Blood pressure of 85/55 indicates hypotension, which can compromise perfusion to vital organs such as the brain and kidneys. Immediate assessment is necessary to determine the underlying cause, such as dehydration or internal bleeding.

Choice B rationale

Hemoglobin level of 7 g/dL is critically low, falling below the normal range of 12–16 g/dL for women or 13–18 g/dL for men. This reflects severe anemia, which may require urgent intervention, including blood transfusion or addressing the cause of anemia.

Choice C rationale

Massive bleeding from the right lower leg is an emergency due to the risk of hypovolemic shock and significant blood loss. Stabilization of the bleeding site and monitoring for signs of systemic impact is required immediately.

Choice D rationale

A temperature of 96.5°F (35.8°C) may signal mild hypothermia or a systemic condition. While it requires follow-up, it is not as immediately life-threatening as the other findings and therefore does not warrant immediate prioritization.

Choice A rationale

Twelve hours without voiding indicates potential acute urinary retention due to ureteral obstruction, risking hydronephrosis or kidney damage, which requires immediate attention to preserve renal function.

Choice B rationale

Hematuria is common with kidney stones and generally not urgent unless accompanied by clots causing retention or excessive bleeding causing hemodynamic instability.

Choice C rationale

Fever indicates infection but at 37.7°C, it is considered low-grade and less urgent compared to obstruction. Normal body temperature is typically 36.1-37.2°C.

Choice D rationale

Cloudy urine suggests infection but lacks the immediacy of urinary retention or acute obstruction, which are potentially life-threatening.