Your client with COPD (Chronic Obstructive Pulmonary Disease…
Your client with COPD (Chronic Obstructive Pulmonary Disease) is admitted to the telemetry floor with sepsis from a UTI (Urinary Tract Infection) and is being treated with Vancomycin 1 gm IVPB q 8 hours. Her second dose of Vancomycin is due in 1 hour. During your assessment, the client tells you they have dysuria and urgency with urination. The vital signs are temp 100.0 F, HR 89, BP 88/60, RR 20, pulse oximetry 95% on RA. The client denies dyspnea, and chest pain. Lungs diminished throughout, nonproductive cough. Urinary output 70 mL/3 hours. Her home medications are ASA 81 mg po daily and metoprolol 25 mg po daily. Which of the following assessment findings require immediate follow-up by the nurse? (Select all that apply)