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  Nurse Progress Note: 1105: Client is alert, oriented × 4,…

  Nurse Progress Note: 1105: Client is alert, oriented × 4, and follows all commands. Chest expansion equal with an anteroposterior ratio of 1:1. Respirations unlabored with diminished breath sounds auscultated in bilateral bases. Heart tones regular. Skin warm and dry with dependent nonpitting lower extremity edema, capillary refill >3 seconds, and pulses palpable throughout. Abdominal dressing intact. Surgical incision below dressing is red and edematous with a pungent odor. Abdomen large, round, soft, and tender to light palpation. Bowel sounds present in all quadrants. Client ambulates with assistance for toileting and in the hallway. VS: T 100.6°F (38.1°C); HR 77 beats/min; RR 15 breaths/min; BP 138/53 mm Hg; SpO2 95% on oxygen at 4 L/min via NC. Reports pain at incision site.1300: Surgeon at bedside. Staples removed from abdominal incision. Wound bed red with purulent drainage. Wound cleaned with saline solution and cultures sent to laboratory. First dose cefazolin administered via left peripheral vascular device; IV flushes easily, site is within normal limits.0730: (2 days later) Client is alert and oriented × 4. Speech is clear. Client reports throat soreness and discomfort when swallowing. Oral mucosa red and inflamed. White patches present on tongue and roof of mouth. Respirations equal and unlabored with diminished breath sounds auscultated in bilateral bases. No cough or drooling noted when swallowing water. Heart tones regular. Pulses palpable and capillary refill >3 seconds throughout. Abdomen round and soft with bowel sounds present in all quadrants. Abdominal wound dressing intact with negative pressure and scant serous drainage. Incision site tender and edema present in surrounding tissues. The nurse collaborates with assistive personnel (AP) to care for the client who is diagnosed with stomatitis secondary to Candida albicans. Which of the following directions would the nurse provide when delegating oral care for this client? Select all that apply.

Case Study: The nurse is caring for a 66-year-old client who…

Case Study: The nurse is caring for a 66-year-old client who has a history of chronic obstructive pulmonary disease (COPD) and is recovering from an explorative laparotomy 5 days ago. 1105: Client is alert, oriented × 4, and follows all commands. Chest expansion equal with an anteroposterior ratio of 1:1. Respirations unlabored with diminished breath sounds auscultated in bilateral bases. Heart tones regular. Skin warm and dry with dependent nonpitting lower extremity edema, capillary refill >3 seconds, and pulses palpable throughout. Abdominal dressing intact. Surgical incision below dressing is red and edematous with a pungent odor. Abdomen large, round, soft, and tender to light palpation. Bowel sounds present in all quadrants. Client ambulates with assistance for toileting and in the hallway. VS: T 100.6°F (38.1°C); HR 77 beats/min; RR 15 breaths/min; BP 138/53 mm Hg; SpO2 95% on oxygen at 4 L/min via NC. Reports pain at incision site. Complete the following sentence by selecting from the list of word choices below.The client findings that require immediate follow-up are [wordchoicea] and [wordchoiceb]