[Answered]: A nurse is caring for a client who has a history…

A nurse is caring for a client who has a history of angina. Nurses’ Notes 1000: Client is awake, alert, and oriented to person, time, and place. Bilateral breath sounds clear and present throughout. Apical pulse regular. 1200: Client reports chest tightness radiating to jaw, not relieved with rest, and periods of nausea, dizziness, and palpitations. Client is diaphoretic and appears anxious. Bilateral breath sounds clear and present throughout. Apical pulse irregular and rapid. Vital Signs 1000: Temperature 37.5° C (99.5° F) BP 150/80 mm Hg Heart rate 90/min Respirations 20/min Pulse oximetry 97% on room air 1200: Temperature 37.5° C (99.5° F BP 180/86 mm Hg Heart rate 112/min Respirations 24/min Pulse oximetry 95% on room air Which of the following findings require follow-up by the nurse? Blood pressure Anxiety Oxygen saturation Breath sounds Irregular heart rate Chest tightness