Current vital signs are:Temperatdre $37.2^{circ} C left(99^{circ} F right)$Heart rate $98 / min$Respiratory rate $24 / min$Blood pressure $14278 mm Hg$SpO, $96 %$ on room airNeurological: Oriented to person and place. Unsure of the time and states cannot remember the MVC or coming to the hospital. Answers questions slowly. Moves all extremities; reports soreness with movement. Follows simple commands.Pupils are equal, round, and reactive to light and accommodation (PERRLA).Hand strength equal bilaterally.GCS 14Integumentary: Gauze dressing to scalp intact, moderate amount of serous drainage noted. Bruise noted to right upper arm. No further bruising or breakdown noted to body.Cardiovascular: Apical pulse regular, rate of 98 , normal sinus rhythm (NSR) on ECG monitor. Pulses palpable to all extremities. No edema noted. Capillary refill less than 2 seconds.Respiratory: Breath sounds clear, respiratory rate of $24 / min$, denies shortness of breath.Gastrointestinal: Bowel sounds active x 4 quadrants. States last bowel movement yesterday. Denies nausea. Genitourinary: Voided $250 mL$ clear yellow urine on the bedpan without difficulty.Which of the following actions should the nurse plan to take in caring for the client? (Select all that apply.)
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[Answered]: Current vital signs are:Temperatdre $37