45. An older adult client with known fluid volume excess pre…

45. An older adult client with known fluid volume excess presents with the following assessment findings: temperature 98.6°F, pulse 92 bpm, respiratory rate 18, blood pressure 166/88 mm Hg, bilateral crackles upon auscultation, and oxygen saturation of 95%. Which nursing action should take priority?

15. The nurse is reviewing the assessment findings for a 73-…

15. The nurse is reviewing the assessment findings for a 73-year-old female client who has a possible intestinal obstruction.  Nurses Notes: 3-20-24 Admitted from the local nursing home with severe abdominal pain and distention, vomiting, and constipation. History of chronic obstructive pulmonary disease (COPD) and hypertension that has been well controlled. Current vital signs: temperature = 99 degrees F (32 degrees C); pulse = 112 beats/min and regular; respirations = 26 breaths/min and slightly labored; blood pressure = 124/66 mm Hg; oxygen saturation = 93% (on room air). Bowel sounds absent in lower quadrants; hypoactive bowel sounds in upper quadrants.  Which of the following client findings would be of immediate concern to the nurse? Select all that apply.