The nurse is caring for a 64 year old client who has a history of hypertension, bipolar affective disorder, 48 pack year history of cigarette smoking and undiagnosed gastrointestinal reflux for which the client takes an ove

The nurse is caring for a 64 year old client who has a history of hypertension, bipolar affective disorder, 48 pack year history of cigarette smoking and undiagnosed gastrointestinal reflux for which the client takes an over the counter antacid. 1430 Client arrives from emergency department client is lethargic but oriented to person and place when aroused. Anteroposterior chest diameter ratio is 1:1 , and respirations are equal and unlabored with no adventitious breath sounds auscultated. Skin is pale and cool to touch. Dependent edema is present in bilateral lower extremities. Abdomen is distended and tender to light palpation. Bowel sounds are hypoactive in all four-quadrant vs HR 111 beats/min, RR 14 breath/min ,BP 149/55 mm hg, spo2 94% on RA WBC 11,200 Hemoglobin 19 Hematocrit 53% Blood urea nitrogen 12mg/dl Creatinine 0.9mg/dl Glucose 112mg/dl Sodium 144 meq/l Potassium 4.3meq/l Calcium 14mg/dl Phosphate 2.1 mg/dl Complete the diagram by selecting from the choices below to specify what potential condition the client is most likely experiencing, 2 nursing actions that are appropriate to take and 2 parameters the nurse should monitor to assess the clients progress