1600: the nurse performs a focused assessment of the client

1600: the nurse performs a focused assessment of the client and obtains current vital signs. The nurse reports the assessment, vital signs, and laboratory findings to the provider. Vital signs: Temp 38.9 C (102 F), BP 128/72, P 117, RR 30, Sp02 92% on room air Client is resting, rouses easily, is oriented to person, place, and time X 4. Answers questions appropriately. Sinus tachycardia, skin warm to touch, and mucous membranes are pink. Respiratory rate is increased, chest with diminished lung sounds, and dry cough noted. The client has produced 250 mL of cloudy urine over last 3 hr. Which of the following prescriptions should the nurse anticipate from the provider? (Select all that apply.) Acetaminophen 650 mg PO every 6 hr PRN fever Vancomycin 500 mg IV intermittent bolus every 6 hr Oxygen via nasal cannula PRN to keep Sp02 2 95 Transfuse 2 units packed red blood cells (PRBC) Enoxaparin 40 mg subcutaneous once daily O Hypothermia blanket

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