medium · NCLEX-RN pharmacology
The RN is assessing a client with a history of heart failure who is receiving IV fluids.
Which cue cluster suggests the nurse should escalate for a new safety threat?
- Capillary refill of less than 2 seconds and warm extremities, for this client.
- Sodium level of 138 mEq/L and potassium level of 4.0 mEq/L, for this client.
- New-onset S_3 heart sound, jugular venous distention, and bibasilar crackles.
- Stable weight and urine output of 50 mL/hour.
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