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    HESI RN Exit Proctored ExamQuestion 25
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    Hesi RN Exit proctored exam

    Patient Data Exhibits Review H and P and nurse's notes. Click to highlight which assessment finding(s) should the nurse attend to right away? Admitted client. Vital signs Temperature: 96.9° F (36.1° C) internal probe via urinary catheter Heart rate: 128 beats/minute, sinus tachycardia (ST) Respirations: 14 breaths/minute Patient Data Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2) The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a PIV line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members. The client opens her eyes to verbal stimuli and follows verbal commands.