A nurse is caring for a client on a medical-surgical unit. Exhibits Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect a finding, click on the finding again. 0830 Client assessment performed. Heart rate 102/min Respiratory rate 20/min Breath sounds clear and equal bilaterally Blood pressure 128/66 mm Hg Temperature 38.9°C (102°F) Oxygen saturation 95% on room air Abdomen soft, nondistended with hyperactive bowel sounds audible in 4 quadrants. Hematocrit 47% (37% to 47%) Hemoglobin 16 g/dL (12 g/dL to 16 g/dL) Potassium 3.3 mEq/L (3.5 to 5.0 mEq/L)