nurse is caring for a client. The nurse is reviewing

nurse is caring for a client. The nurse is reviewing the client’s medical record. Which of the following findings should the nurse identify require immediate follow-up? Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Select 4 findings that require immediate follow-up. Nurses’ Notes Blood pressure Day 1, 1530: ECG results Client presents to ED with reports of chest pain. Client states, “I Diaphoresis was working in the yard today and begin feeling pain in my Respiratory rate chest that began radiating down my left arm, then I called 911.” Weakness Client administered nitroglycerin sublingual x1 by paramedics and effective. Client reports chest pain is a 5 on a scale of 0 to Nausea 10. S1, S2 head upon auscultation, no murmur detected. Lung Oxygen saturation sounds are clear. Bowel sounds are normoactive. Peripheral pulses +2 bilaterally. No edema present. Day 1, 1745: Client reports chest pain is an 8 on a scale of 0 to 10. Client states, “I feel tightness in my chest and it’s hard for me to breathe. I feel nauseous too.” Client appears weak and diaphoretic. Breathing is labored. Nitroglycerin sublingual x1 administered.

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