The nurse is caring for a newly

The nurse is caring for a newly admitted 59-year-old male client in the medical surgical unit. History and Physical: The client arrived to the emergency department complaining of a “swelling abdomen,” some shortness of breath, and unexplained bruising. Client states that he was diagnosed with Hepatitis C, but stopped taking the medications because of the side effects. He drinks 5-8 beers per week and smokes tobacco, about 2 packs a week. He denies usage of drugs. New diagnosis of cirrhosis has been confirmed and client has been transferred to medical surgical unit. Nurses’ Notes: 1245: Client is awake but appears lethargic. He is oriented to person, place, and time. Skin is warm and dry upon touch, yellow in color with bruising noted on upper back and left arm. The client states that his skin is “itchy” at times. He also reports of a “swelling abdomen” and shortness of breath. Diminished breath sounds at lung bases bilaterally. Abdomen is distended and slightly tender upon palpation. Last bowel movement 4 hours ago with clay-colored stools. Peripheral pulses are 2+ with capillar refill time of less than 2 seconds. Call light within reach. Will continue to monitor. Vital signs: 1245: P 190 RR 20 BP 119/70 T: 37.5 C (99.5 F) O2 saturation 98% on room air Image transcription text Sodium (Na) 130 mmol/L 135-145 mmol/L (130 mEq/L) (135-145 mEq/L) Potassium (K) 3.3 mmol/L 3.5-5.0 mmol/L (3.3 mEq/L) (… Show more Which of the following findings require follow-up? Select all that apply. 1. Vital signs 2. Laboratory results 3. Abdominal assessment 4. Client orientation 5. Respiratory assessment 6. Peripheral pulses 7. Capillary refill time 8. Integumentary assessment

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