The nurse is completing an assessment on a patient who was just admitted from the emergency department. Which assessment findings would require immediate attention? Select all that apply
a. Temperature: 38.6 ° C
b. Systolic blood pressure: 150 mm Hg
c. Respiratory rate: 22 breaths per minute
d. Heart rate: 130 beats per minute
e. Oxygen saturation: 95%
f.
Sudden restlessness
ANS: A, D, F
The following examination findings require immediate attention:
High or low temperature: (36.1 ° C or 37.8 ° C)
High or low blood pressure: (systolic pressure 90 mm Hg or 160 mm Hg)
High or low number of respirations: (12 or 28 breaths per minute)
High or low heart rate: (60 or 90 beats per minute)
Oxygen saturation: 92%
Sudden restlessness or anxiety, altered level of consciousness, confusion, or difficulty in arousing
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