[Answered]: Before answering this question, review the…

Before answering this question, review the client’s health information in the EHR. Identify the following findings that require nursing action. Select to highlight four (4) correct answers. Vital Signs: Temp. 98.4 °F (36.8 °C); HR 102; RR 22; BP 140/92 (108); SpO2 92% on RA; Pain with deep inspiration. Nursing Assessment: Cooperative with moderate distress. Skin warm/dry, without lesions. PERRLA, Lungs with bilateral crackles, heart rate and rhythm regular with an occasional abnormal beat. No murmurs present, no S3, and S4. JVD present. Peripheral pulses 2/4, DP and PT pulse 1/4; 3+ bilateral pedal edema. Abdomen soft, active bowel sounds x 4; last BM 3 days ago.