The nurse is caring for a client who has the following history and assessment findings:

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The nurse is caring for a client who has the following history and assessment findings: – T5 spinal cord injury SCI 6 months ago – Flushed face – Profuse sweating – Reports blurred vision – BP 184/95 – Pulse 68 -Pulse oximeter 95% What actions should the nurse take first?

• Assess the skin for pressure injury

• Adjust the room temp for comfort

• Prepare to administer enema Or Palpate clients bladder

 
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