The nurse is caring for a 63 year old female with history of…
The nurse is caring for a 63 year old female with history of hypertension and complaints of shortness of breath. Day 1: Bilateral breath sounds clear and present throughout, Weight 80kg(176 LB), Urine output 480ml/8 hours. Vital Signs: Temp-99.7, BP 108/50, Pulse 98, Resp rate-20, O2Sat 95% Room Air. Day 4: Breath sounds scattered, crackles heard bilaterally. Apical heart rate rapid and irregular. Audible s3 Gallop. Weight 82.1kg(181 LB). Urine output 320ml/8 hours. Vital Signs: Temp-98.2, BP 138/80, Pulse 112, Resp rate-28, O2Sat 88% Room Air. A Nurse is reviewing the assessment finding for the client on day 4. Which of the following findings require further action?
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