A nurse is caring for an older adult client in the emergency…
A nurse is caring for an older adult client in the emergency department. Which of the following findings require immediate follow-up? Select all that apply. Current vital signs: Temperature 39.3° C (102.8° F) Heart rate 93/min Respiratory rate 24/min Blood pressure 88/58 mm Hg Oxygen saturation 95% on room air Medical History: Older adult client, lives with family. Family states the client is normally alert and oriented but began to display confusion over the last 6 hr and has a new onset of incontinence. Client reports dizziness and constant low back and flank pain. Urinalysis: Appearance: cloudy Color: dark amber Odor: foul pH: 8.0 Protein: 6.5 mg/dL Specific gravity: 1.035 Leukocyte esterase: positive Nitrates: present Ketones: none Glucose: none White blood cells: 8 Red blood cells: 1
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