The nurse has been assigned a 54 year old patient, C.T., who…
The nurse has been assigned a 54 year old patient, C.T., who has been brought into the emergency department by a daughter because of sudden weakness and a decreasing level of consciousness. The daughter says that C.T. has been reporting nausea, with associated abdominal and back pain, and usually C.T. is very alert and oriented, but today is increasingly lethargic. The nurse reviews the chart below. Medical History Initial Vital Signs Hypertension Atrial Fibrillation Diabetes Mellitus Type 2 Blood Pressure: 102/38 mm Hg Heart Rate: 102 beats/min O2 saturation: 76% Respiratory Rate: 30 breaths/min Temperature: 102.4 F The Health Care Provider orders an infusion of 1000 ml of normal saline bolus (wide open). Which action is most important to evaluate an adverse reaction to the rapid fluid bolus infusion?