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Library Resources Microsoft Office Student Portal Nursing Flowsheets Lab Diagnostics MAR Other before answering this question, review the client s health information in the EHK. Listen to the client and nurse. NURSING ASSESSMENT NOTES 0:18 1x 9/9 Neuro/Cognitive: Alert, oriented x 4. Lethargic and reports feeling fatigued. Speech 0715 is even and clear-pupils 4 mm PERRLA bilaterally. Download Audio Transcript Cardiovascular: $1 and $2 sound present. HR regular and even. No edema. Cap refill less than 3 seconds. +sensation in all extremities. Identify the actions the nurse should take. Select all that apply. Respiratory: Breathing regular, even, unlabored. Lung sounds clear bilaterally. No cough. Select one or more: Gastrointestinal: BS present x 4 quadrants, hyperactive. LLQ ostomy is red, moist. Monitor the client's pain hourly. Draining formed, a brown stool which is hemoccult positive. Abdomen soft, distended, diffusely tender to palpation. +nausea and anorexia but denies vomiting Administer PRN 1 mg hydromorphone IVP per order. Reports weight loss of 9 kg. over the last 3 months. Notify the provider and request a basal rate for the PCA pump. Integumentary: Pale, cool to touch. No skin breakdown. Scattered ecchymosis. ) Assess the client's level of alertness and orientation. Mucous membranes dry, pale, and cracked. Encourage family upon arrival to push the PCA pump if the client is too weak. Pain: Rates 6/10 aching diffuse abdominal pain, which has worsened over several Perform a complete pain assessment. weeks. Headache that rates 4/10 dull, aching, and constant. ) Put the client's thumb on the PCA pump and push down on top of the client's thumb. Lines/Drains/Tubes: 19-gauge right subclavian port accessed. 0.9% normal saline at Monitor the client's sedation level, respiratory rate, and pulse oximetry level. 50 mL/hour. Dressing clean, dry, intact. Ensure the pump is in locked mode. 9/9 Nursing Note: To endoscopy via stretcher. Family escorted to the waiting room. Continue 0745 9/9 Nursing Note: Client resting quietly in a stretcher after the procedure. Lethargic and 0900 requires verbal stimuli to awaken. The client occasionally moaning in pain and vomiting. The family verbalizes concern and anxiety about the results of the client's colonoscopy