What foods should the practical nurse (PN) recommend to a client as good sources of vitamin K? Select all that apply.

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

A. Take the child's pulse

Assessing the pulse is crucial to determine if the child has a heartbeat and to evaluate the effectiveness of CPR. This helps to determine the current cardiovascular status of the child and the urgency of further resuscitation efforts.

F. Determine if the child's airway is clear

Ensuring a clear airway is a priority in any emergency situation. A blocked airway can prevent effective ventilation and oxygenation, which is critical for a child who has experienced a near-drowning incident.

D. Start a peripheral IV line

Starting a peripheral IV line is important for administering fluids and medications that may be necessary for resuscitation and stabilization. It allows for rapid access to the child's circulatory system for necessary interventions.

E. Look for any open wounds

Checking for open wounds is necessary to identify any immediate sources of bleeding or potential infections that need to be addressed. It is part of a thorough initial assessment to ensure comprehensive care for the child.