SOLVED1272
3. A nurse is caring for a client in the emergency department (ED). Vital Signs 1500: Blood pressure 118/76 mm Hg Heart rate 92/min Respiratory rate 22/min Temperature 38.1° C (100.6° F) Oxygen saturation 95% on room air 1600: Blood pressure 126/84 mm Hg Heart rate 104/min Respiratory rate 24/min Temperature 38.5° C (101.3° F) Oxygen saturation 92% on room air Nurses’ Notes 1500: Client presents with chills, body aches, headache, and cough for the past 3 days. Client reports cough has worsened today with occasional yellow sputum expectorated. Client states, “My head hurts all over,” and rates pain a 5 on a 0 to 10 pain scale. Client denies vomiting but reports a poor appetite and eating very little since becoming ill and has not had a bowel movement for 2 days. 1600: Client’s face is flushed, cool cloth placed on forehead and ice chips provided. Breathing somewhat labored while resting in bed. Head of bed elevated, extra blanket removed. Small amount of thick, yellow sputum noted with coughing. Client rates headache a 6 on a 0 to 10 pain scale.
SCIENCE
HEALTH SCIENCE
NURSING
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