Nurses’ Notes 1000: Client is awake, alert, and oriented to…
Nurses’ Notes 1000: Client is awake, alert, and oriented to person, time, and place. Bilateral breath sounds clear and present throughout. Apical pulse regular. 1200: Client reports chest tightness radiating to jaw, not relieved with rest, and periods of nausea, dizziness, and palpitations. Client is diaphoretic and appears anxious. Bilateral breath sounds clear and present throughout. Apical pulse irregular and rapid. Vital Signs 1000: Temperature 37.5° C (99.5° F) BP 150/80 mm Hg Heart rate 90/min Respirations 20/min Pulse oximetry 97% on room air 1200: Temperature 37.5° C (99.5° F) BP 180/86 mm Hg Heart rate 112/min Respirations 24/min Pulse oximetry 96% on room air Which of the following findings require follow-up by the nurse? (Select all that apply)