hard · NCLEX-RN basic-care
The nurse reviews the EHR entries from 13:00 and 13:15. Which assessment findings require immediate nursing attention? Select all that apply.
- Blood pressure 94/58 mm Hg
- Heart rate 108 beats/minute
- Stoma is pink and moist
- 1400 mL ileostomy output over 5.25 hr
- Peristomal skin maceration and denuded areas
- Assistance of 1 required for ambulation
- BUN 24 mg/dL
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