The nurse notes that a patient's blood pressure has been trending lower since admission. Which intervention demonstrates the nurse using information to guide nursing care? Select all that apply.
A) Measuring body temperature
B) Measuring intake and output
C) Monitoring for blood in stool
D) Monitoring for blood in urine
E) Monitoring level of consciousness
B) Measuring intake and output
C) Monitoring for blood in stool
D) Monitoring for blood in urine
Explanation: A) Body temperature changes would not reflect clinical judgment in this situation.
B) Low blood pressure can be caused by low oral fluid intake or excessive urine output. Measuring intake and output reflects clinical judgment.
C) Low blood pressure can be caused by bleeding. Monitoring for blood in stool reflects clinical judgment.
D) Low blood pressure can be caused by bleeding. Monitoring for blood in urine reflects clinical judgment.
E) Monitoring level of consciousness would not reflect clinical judgment in this situation.
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