You are caring for a 55-year old patient who was admitted to the hospital after
experiencing a 10-pound weight gain over the past 3 days. The patient’s vital signs are:
- Blood Pressure: 98/56 mm Hg
- Heart Rate: 108/min
- Respiratory Rate: 32/min
- Temp: 98.2 F (36.8 C)
- Oxygen saturation: 90% on room air.
The patient has a non-productive cough and, upon auscultation of the client’s
lungs, there are crackles in the bases bilaterally. The patient lives alone and independently performs all activities of daily living.
Identify the expected and unexpected assessment findings. What assessment findings are of immediate concern? Based on the collected assessment findings, what potential nursing actions would you anticipate performing to address the unexpected assessment findings?