A nurse is admitting a patient to a unit from the  emergency…

A nurse is admitting a patient to a unit from the  emergency department. The nurse reviews thepatient’s clinical record and assesses the patient. Patient’s Clinical RecordVital SignsTemperature: 100°F rectally.Pulse: 100 beats/minute and regular.Respirations: 10 breaths/minute and shallow.Blood pressure: 138/88 mm Hg.Transfer Nurse’s Note 10-9-2013 1330Patient transferred to room via stretcher from the emergency department with side rails raised. Patient in semi-Fowler position, skin appears flushed and patient is diaphoretic. Patient states that she feels warm, has no pain but is very sleepy. IV in right hand set at ordered rate of 125 mL/hour. IV in left hand isan intravenous lock. Both IVs are dry and intact, no clinical indicators of infiltration or inflammation noted. Patient attempted to void on a bedpan but was unsuccessful. Has not voided since 1030. Oxygen running at 2 L/minute via nasal cannula. Tylenol 650 mg administered at 1300. Primary Health-Care Provider’s Orders 10-9-20131. Bedrest.2. Regular diet.3. Vital signs every 4 hours.4. I&O.5. Tylenol 650 mg PO every 4 hours prn for temperature 101.2°F.6. IVF 1000 mL 0.45% NaCl with 20 mEq KCl at 125 mL/hour.7. Oxygen 2 L via nasal cannula. What concern should be the nurse’s priority?