The nurse is assessing a patient's vital signs. What should the nurse include in this assessment?
1. peripheral pulses
2. pain level
3. ability to ambulate
4. urine output
Correct Answer: 2
Pain is increasingly being referred to as the "fifth vital sign," with recommendations to include assess pain assessment in every vital signs assessment. Assessment of peripheral pulses is done to check for presence and strength; it is not routinely done to assess a pulse rate. Ambulation and urine output are not vital signs.
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