The nurse in a long-term care facility reviews the nurse's notes in the client's record. The nurse is MOST concerned by which entry?
1. "Indwelling catheter draining clear urine and the pH is 6.5"
2. "The client's skin is blanched over the scapular areas."
3. "Vital signs are within normal limits."
4. "The client drinks three glasses of orange juice every day."
