[Expert Solution]: Ramona Stukes Initial Nursing Assessment…

Ramona Stukes Initial Nursing Assessment 1500: Received awake, alert, and oriented to person, place, and time. PERRLA. Breath sounds clear in bilateral lungs; respirations even and unlabored. Nasogastric tube to right nare to low intermittent suction with no drainage in tubing and small amount of tan drainage in canister. No skin breakdown observed around nares or under tape. IV of Dextrose 5% in 0.45% sodium chloride with 20mEq Potassium Chloride infusing at 125 mL/hr in left forearm without redness or swelling observed. Capillary refill less than 3 seconds in bilateral upper and bilateral lower extremities. Abdomen soft, nondistended, hypoactive bowel sounds active in all quadrants. Abdominal incision midline and intact with sutures. Skin warm and dry; color appropriate for genetic background. Reports pain a 5 on a scale of 0 to 10 in their abdomen as burning. Encouraged client not to wait until pain gets too severe before requesting pain medication. Client ambulates with assistance but remains in one position while in bed because they are afraid to move and afraid to hurt. Vital signs: temperature 37.4° C (99.4° F), Heart rate 98/min, Respirations 18/min, Blood pressure 118/68 mm Hg, SpO2 is 96% on room air; 98% after spirometry tidal volume of 1300 mL. Which of the following concerns should the nurse address while providing client care? (Select all that apply.) Physiological: Mobility Physiological: Nutrition Safety: Injury prevention Physiological: Thermoregulation Physiological: Pain Safety: Home environment Physiological: Tissue Integrity Physiological: Elimination