8. A nurse is assessing the vital signs of several clients. Which client responses require the nurse to perform a further nursing assessment? Select all that apply 1)Pulse rate of 68 and regular
2) Rectal temperature of 99.8 F
3) Pain level of 5 on a to 10 scale
4) Blood pressure measurement of 118/78 5) Respiratory rate of 28 breaths per minute
The responses that require the nurse to perform a further nursing assessment are:
3) Pain level of 5 on a 0 to 10 scale
5) Respiratory rate of 28 breaths per minute
The client responses that require the nurse to perform a further nursing assessment are:
1) Pain level of 5 on a to 10 scale
3) Respiratory rate of 28 breaths per minute
These two responses indicate potential issues that require further assessment. The pain level of 5 on a scale of 1 to 10 suggests that the client may be experiencing discomfort or pain that needs to be addressed. The respiratory rate of 28 breaths per minute is higher than the normal range, which may indicate respiratory distress or a breathing problem. The nurse should further assess these clients to determine the cause of their pain and high respiratory rate.