A nurse is caring for a client.

Exhibit 1 Vital Signs 0800: Exhibit 2 Temperature 37.6° C (99.7° F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min Pulse oximetry 97% on room air 0830: Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min Pulse oximetry 93% on room air Select the 4 findings that require immediate follow-up.

This is because chest percussion uses clapping of the chest using a cupped hand to vibrate the airways of the lungs and move and break apart the mucus inside the lungs.
Covering the area of percussion with a towel can help to reduce discomfort during the procedure.
Choice B is wrong because postural drainage should not be scheduled after meals.
It is best to schedule postural drainage before meals or at least 1-2 hours after meals to prevent discomfort or vomiting.

Choice Cis wrong because, during vibration, the client should inhale deeply and exhale slowly.
Choice Dis wrong because percussion should not be performed over the lower back.
It should be performed over the chest and back, avoiding areas such as the spine and breastbone.

A. Change the tubing set every 72 hr:Continuous enteral feeding tubing sets should generally be changed every 24 hours to reduce the risk of bacterial contamination. Changing every 72 hours is too long and increases infection risk.

B. Aspirate residual volume every 4 hr:Aspiration of residual volume every 4 hours is standard practice when providing continuous enteral feedings. This ensures the client is tolerating the feedings and helps prevent aspiration or overfeeding. Large residual volumes may indicate poor gastric emptying.

C. Flush the tubing with 10 mL of water every 2 hr:The tubing should be flushed with 30 mL of water every 4-6 hours (depending on protocol), not just 10 mL, to maintain tube patency and prevent clogging.

D. Heat the formula to 40.5° C (105° F):Formula should not be heated to such a high temperature. It should be administered at room temperature to avoid discomfort and potential damage to the gastrointestinal tract.