A 88 year-old in the ICU on

A 88 year-old in the ICU on the ventilatory support for 24 hours has history of pneumonia, hypertension, CAD, heart failure, and COPD. The client opens their eyes to verbal stimuli, slight movement of all extremities, lungs crackles in lower fields bilaterally, perpheral pulses +2, cap refill less than 3 sec, ankle edema 2+, and skin warm to touch. Weight gain 1kg from yesterday and urine output 30ml for 2 hours and VS: 96/50 (65), cardiac rhythm listed below, respiratory rate 22, pulse ox 95% on FiO2 40%, temp 37.1. The current labs are glucose 165, potassium 3.5, sodium 145, chloride 100, BUN 25, creatinine 1.50, GFR 90, INR 1.0, BNP 2500, and WBC 10,000. Which pritority clinical findings should the nurse be concerned with? Select all that apply. Image transcription text @2013 Medical Training and Simulation LLC www.practicalclinicalskills.com 1. crackles in lower fields bilaterally and ankle edema 2+ 2. BP 96/50 (65), cardiac rhythm shows sinus tachycardia at 130 and respiratory rate 22. 3. BUN 25, creatinine 1.50, and urine output 30 ml for 2 hours. 4. Weight gain of 1kg 5. BNP 2500 SCIENCE HEALTH SCIENCE NURSING NURS 2444

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