The nurse assessing an 85-year-old patient who has been on bed rest for a fractured hip finds the patient flushed with a temperature of 100° F,pulse of 100,and respiration rate of 24.The next intervention should be to assess:

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The initial assessments are the cardinal signs of pneumonia.The breath sounds should be assessed next to determine the presence of any adventitious breath sounds.BP will also need to be assessed,but the breath sounds are more important with the signs and symptoms present.Abdominal distention is indicative of a gastrointestinal problem.Amount of urinary output is important to an ongoing assessment but not a priority in the present circumstances.

The Nurse Assessing an 85-Year-Old Patient Who Has Been on Bed