While Assessing an Older Adult Patient with Fluid Excess, the Nurse

While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first?

A) Provide oxygen at 2 L per nasal cannula.
B) Place the patient in a high Fowler position.
C) Provide a urinal and encourage the patient to void.
D) Lay the patient flat in bed to listen to bowel sounds.