Management of CareQuestion 4 of 120
The nurse is caring for four clients. Applying the ABC framework, which finding requires the most immediate action?
a.Blood pressure of 148/88 mm Hg
b.Temperature of 100.8 F (38.2 C)
c.Reports of mild incisional pain
d.Oxygen saturation of 86% on room air
Explanation
An oxygen saturation of 86% reflects a breathing and oxygenation emergency and takes priority over an elevated blood pressure, a low-grade fever, or mild pain.
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