A patient is to receive a physical examination before starting immune sera therapy. What would the nurse assess for?
A) Assess mental status changes
B) Physical characteristics
C) Pulse pressure
D) Adventitious breath sounds
D
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Perform a physical assessment to determine baseline status before beginning therapy and for any potential adverse effects; inspect for presence of any skin lesions to monitor for hypersensitivity reactions; monitor temperature to monitor for possible infection, pulse, respirations, and blood pressure; auscultate lungs for adventitious sounds; assess level of orientation and affect to monitor for hypersensitivity reactions to the vaccine.
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