While Assessing an Older Adult Patient with Fluid Excess, the Nurse

question 4

Multiple Choice

While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which of the following actions should the nurse take first?

• A)Place the patient in a high Fowler's position.
• B)Provide a urinal and encourage the patient to void.
• C)Provide oxygen at 2 L per nasal cannula.
• D)Lay the patient flat in bed to listen to bowel sounds.

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