[Verified Answer]: The nurse is documenting the initial…

The nurse is documenting the initial encounter on a 9 year old client in the ER. Select to highlight the findings that the nurse should address immediately. Select all that apply. Client is awake and alerty, sitting in the ER bed. Normal S1 and S2 sounds, no murmur. Normoactive bowel sounds. Expiratory wheezes heard bilaterally, prolonged expiratory phase. Mild intercostal retractions. Nonproductive, dry cough. Client coughing frequently. Pulses 2+ in all four extremities, capillary refill time less than 3 seconds. Moves all four extremities with adequate strength and tone. Pupils equal, round, reactive to light. Clear nasal discharge. Pharynx erythematous, but no purulent exudate seen. Dad at bedtime. Client drinking juice. Placed call light withing reach. Bed rails raised x1. Temp 99.2 HR 75 bpm RR 30 breaths/min SpO2 92% on room air BP 105/72 mm Hg The nurse just received a set of client care providers. Complete the sentences. The nurse should first