The nurse is caring for a client in the Emergency Department…

Questions

The nurse is cаring fоr а client in the Emergency Depаrtment (ED). Review the nurse's nоtes and assessment findings belоw. After reviewing this information, complete the table by identifying the potential condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.  Nurse's Notes & Assessment Findings:  Client presents with complaints of chest pain which they state is radiating to their upper back. Client states this started earlier this morning and that the pain is exacerbated by breathing deeply or moving their body position. Physical assessment reveals that lung sounds are clear to auscultation, heart sounds are muffled and distant with S1 and S2 noted, neck veins are distended, and client skin is cool to touch.  Initial vital signs upon arrival to the ED: 99.7 F - 105 bpm - 18 breaths/min - 158/88 mmHg - 92% room air  Repeat vital signs 30 minutes later: 99.9 F - 110 bpm - 22 breaths/min - 144/86 mmHg - 91% room air    Actions to Take Parameters to Monitor  [action1] Potential Condition [parameter1] [condition]  [action2] [parameter2]

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