The nurse assesses the client’s pain and determines that the

NGN: states, I am feeling extremely anxious right now. The client has decreased breath sounds in the left lower low. His mucus membranes are dry. He has a productive cough with thick, yellow secretions. His capillary refill is four seconds. Vital signs, temperature 100.2. Heart rate 101 bpm, respiratory rate 28 breaths per minute, blood pressure 145/89, oxygen saturation 90% on room air. (for each body system click to specify the assessment findings that indicates hypoxia) Cardiovascular: heart rate 100 bpm, capillary refill for seconds, blood pressure 145/89. Neurological: anxious, awake and alert, restless. Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm, productive cough.

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