A 78-year-old woman in a rehabilitation unit has type 2 diabetes mellitus and hypothyroidism. She has been sleeping poorly and reports increased fatigue. Baseline vitals were BP 126/74, HR 76, RR 16, SpO2 97%, temp 36.9°C. The LPN/VN now finds BP 88/52, HR 118, RR 22, SpO2 94%, temp 36.7°C. What should the LPN/VN do first?
- Focus on the client's report of poor sleep since her temperature is still normal.
- Report the falling blood pressure and rising heart rate to the RN or provider right away.
- Chart the new vital signs in the record and continue with the client's scheduled care, without notifying the RN or health care provider.
- Perform a full admission-style neurological and cardiovascular assessment before saying anything.