Highlight the assessment findings that require immediate follow-up by the nurse

Highlight the assessment findings that require immediate follow-up by the nurse

Scenario: A 72-year-old client, with a history of heart failure HF and allergy to peanuts, has been in the surgical critical care unit for past 3 days following abdominal surgery for stomach cancer. The client’s central line has become thrombosed and was successfully replaced.

Highlight the assessment findings that require immediate follow-up by the nurse:

Approximately 10 minutes after the insertion, the client reports feeling flushed and states, “my heart is just racing.” The client is visibly flushed and clammy to the touch. Vital signs include blood pressure (BP), 60/Doppler; heart rate (HR), 160; respiratory rate (RR), 30; and temperature (T), 99°F.

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