SOLVED604

Keaton Henderson Initial Nursing Assessment The client is awake and alert x 4. He rates his pain at a 5 on a scale of 0 to 10. Reports pain at the incision site. entry wound, and with inspiration. Bilateral lung sounds are coarse. Heart sounds are clear. Right thoracotomy incision is open to air with no signs of redness or swelling. GSW entry wound to the right chest is open to air with 10 sutures in place, some redness around the site noted. Chest tube insertion site is dressed and intact. There has been 40 mL of bloody drainage from the chest tube in the last 2 hr. Vital signs are temperature of 36.9° C (98.4° F), pulse 91/min, respirations 20/min, blood pressure 140/72 mm Hg, and oxygen saturation of 97% on 2 L NC. Lab ,values from this morning are Hgb 11 g/dL, Hct 34%, Na 142 mEq/L, K 4.3 mEq/L, and WBC 9500/mm’. Which of the following concerns should the nurse address while providing client care? (Select all that apply.) Physiological: Infection 2 Physiological: Pain I Physiological: Tissue Integrity I Physiological: Gas Exchange Physiological: Thermoregulation • Physiological: Fluid and Electrolyte E Psychosocial: Cognition I Physiological: Clotting _ Physiological:
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HEALTH SCIENCE
NURSING

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