Client: Maria Thompson, 74 years old, admitted for pneumonia…
Client: Maria Thompson, 74 years old, admitted for pneumonia three days ago. When the nurse enters the room, Maria is sitting up in bed, eating breakfast. She says, “I just feel more tired today.” Assessment findings: Skin warm and slightly flushed Respirations 26/min, shallow Occasional cough producing thick yellow sputum Crackles heard in both lower lobes SpO₂ 90% on 2 L nasal cannula HR 110 bpm, BP 148/86 mmHg Fingers cool, capillary refill 5 seconds Reports shortness of breath when talking IV site is slightly red and tender Question: Which assessment findings should the nurse recognize as most concerning and requiring immediate follow-up? Select all that apply.