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The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action? 1.Heart rate 86 2.Reddened area on sacrum 3.Nonproductive cough 4.Urine output of 50 mL/hour

The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action?
1.Heart rate 86
2.Reddened area on sacrum
3.Nonproductive cough
4.Urine output of 50 mL/hour

 
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