42-year-old male patient presents in the ICU

42-year-old male patient presents in the ICU with a diagnosis of MVA. Vital signs are as follows: P 85, RR 13, BP 102/42, O2 sat 91% on room air, Temp 38, Pain 6/10. The patient’s EKG shows a normal sinus rhythm with occasional ectopy. Head-to-toe assessment is as follows: neurologically follows commands, PERLLA, respirations even and unlabored, clear breath sounds with incentive spirometer exercises measuring 1350mls, cardiac S1 and S2 heard, bowel sounds in all 4 quadrants, urine output in urinal measuring 750mls of clear urine, controlled movement in all 4 extremities, patient has been delirious and disoriented. Skin is warm and pink, edema noted on left arm with a hot red patch of skin above central line dressing. Triple lumen central line has been flushed and Curo caps have been placed on the ends. What are the highest priority client findings? Select the top 3 findings. a. EKG with ectopy b. hypotension c. delirious d. cardiac sounds e. urine output f. incentive spirometer measurement g. hot red skin h. temp 38

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