A nurse is caring for a 64-year-old client admitted with com…
A nurse is caring for a 64-year-old client admitted with community-acquired pneumonia. The client has been stable on room air for the past 12 hours. Current Assessment (0800) Temperature: 37.4°C (99.3°F) Heart rate: 102/min (previously 82/min) Respiratory rate: 20/min Blood pressure: 128/76 mmHg Oxygen saturation: 95% on room air Lung sounds: Crackles in the right lower lobe Skin: Warm, slightly pale Behavior: Restless, mildly anxious, reports “I can’t focus.” Capillary refill: 3 seconds Which nursing actions are most appropriate immediately? Select all that apply (SATA)
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