A nurse is caring for a client who has right sided paralysis…

A nurse is cаring fоr а client whо hаs right sided paralysis fоllowing a stroke. Select the information in the client's medical record that requires intervention by the nurse (Select all that apply).    Nurses' Notes   Day 1: Client is alert and oriented. Client is repositioned every 2 hr.  Passive range of motion exercises to affected extremities performed once each day.    Day 5: Client is alert and oriented. Client is repositioned every 2 hr.   Passive range of motion exercises to affected extremities performed once each day.  Feet warm, pedal pulses 2 + bilaterally.   Joint contracture noted to right wrist.   Right heal with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable redness, skin intact.