A 32-year-old male client in a skilled nursing facility is recovering from a traumatic brain injury with a new seizure disorder. He was started on phenytoin 3 days ago, and the RN provided initial teaching on seizure precautions and medication adherence. This morning his vital signs are BP 118/76, HR 88, RR 16, SpO2 97% on room air, temp 98.6°F, and he is alert and oriented. Two hours later, the LPN notes his RR has dropped to 10, SpO2 is 89%, and he is difficult to arouse, though he was easily awakened at breakfast. The LPN also reinforces earlier teaching about calling for help immediately if he feels an aura or notices jerking movements before a seizure begins, then confirms his understanding using teach-back. Which action should the nurse take first?
- Notify the RN immediately about the drop in respiratory rate, low SpO2, and decreased arousability.
- Remind him to take his phenytoin with food but skip discussing when to call for help.
- Adjust his oxygen flow rate and determine independently that he is postictal from an unwitnessed seizure.
- Document the decreased respiratory rate and arousability in the chart and continue routine rounds without notifying the RN.