Stage 1 — Recognize cues. Review the 0700 hospice handoff. Highlight the findings that require the nurse's follow-up.

Quick answer
Highlight new Cheyne-Stokes pattern, BP is 96/58, pockets fluid in his cheek, and grimaces and reaches into the air.

Why this is correct
Each correct cue is a change from Mr. K's own baseline that alters today's care. A new periodic breathing pattern and a blood pressure falling from 112/70 support a probable last-days transition; his son has asked to be called when such signs appear, so these changes require notification and family explanation. Pocketing fluid means oral medications are now an aspiration risk and the prescribed subcutaneous route is needed. Grimacing and reaching are behavioral signs of pain or distress in a client who cannot self-report and require a prompt comfort assessment.

Easy analogy or mental picture
Imagine a weather log for a place that is always windy: the steady wind (his COPD signs) is not news, but a new pattern in the sky and a falling barometer tell you a storm is arriving today.

Memory hook
In chronic illness, act on what is new, not on what is abnormal.

NCLEX decision rule
For a client with chronic abnormal findings, compare each finding with the documented baseline; a stable abnormal value is context, while a new pattern or downward trend requires follow-up.

Why the other choices are wrong
Pursed-lip breathing, clubbed fingernails, and respirations of 28/min look like respiratory distress but have been present throughout his stay from advanced COPD and cancer. SpO2 is 86 percent is within his documented 84 to 88 percent range on usual oxygen, and in comfort care oxygen is adjusted to comfort, not to a number. Temperature is 37.2 C is not a fever, ankle edema is unchanged at 1+, and last bowel movement was two days ago is expected with minimal intake; the soft, nondistended abdomen and 90 mL bladder scan show it is not the source of his distress.