Client lethargic-nods head to indicate pain

Reference no: EM133680756

Question

A hospice nurse is caring for a client. Nurses' Notes Day 1 1000: Client lethargic, nods head to indicate pain. Extremities cool to touch, pale. Breath sounds labored, irregular, scattered rhonchi heard throughout. ( Day 2 1000: Client nonresponsive to verbal stimuli; moaning with grimacing when repositioning; mottling to lower extremities. Breath sounds with audible rhonchi, irregular, tachypnea; bladder incontinency. Vital Signs Day 1 1000: Temperature 38.5°C (101.3°F). Blood pressure 78/46 mm Hg Heart rate 112/min Respiratory rate 26/min, irregular SaO2 85% on O2 at 2 L/min via face mask with 40% humidified air Day 2 1000: Temperature 38.6°C (101.5°F) Blood pressure 68/42 mm Hg Heart rate 91/min Respiratory rate 32/min, irregular SaO2 85% on O2 at 2L/min via face mask with 40% humidified air Which of the following actions should the nurse plan to take? Select all that apply: Give client mouth care every 2 hr Administer an opioid narcotics to the client Increase temperature to the client's room Insert a nasogastric tube for enteral feeding/ Elevate client's head of the bed.

Reference no: EM133680756

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