The nurse reviews the nurses’ notes documented by the nurse from the last shift who was assigned to care for a 65-year-old female African American client. The client had a Heart Failure exacerbation 3 days ago and is planning to be discharged tomorrow.

1805: Alert and oriented. Walked in the hall tonight with a walker independently. Reports increasing swelling of the ankles, “feeling funny” and anxious for the past hour. Is excited to go home tomorrow and follow up with PT. Spouse states that the client has been coughing periodically since stopped walking and returned to the room. No adventitious or abnormal breath sounds. Neck veins are flattened. Current VS: T = 99.4°F (37.3°C); HR = 88 BPM; RR = 20 bpm; BP 102/58 mm Hg; SpO2 = 93% on RA. Will recheck client and VS in 1 hour.

1922: Reports “a little” difficulty breathing and  has a dry hacking cough but denies chest pain. Auscultated faint fine crackles in bilateral lobes. Skin is warm. VS: T = 99.4°F (37.3°C); HR = 105  BPM; RR = 26 bpm; BP 94/52 Hg; SpO2 88% on RA. Oxygen initiated at 2/min via NC and HOB in Fowler position. MD notified and awaiting orders.

For each body system listed below, select the client findings that would be of immediate concern to the nurse. Each body system may support more than one client finding, but at least one option should be selected for each system.