A 35-year-old man presents to the emergency department following an unrestrained head-on collision where his chest struck the steering wheel. During the initial assessment, the patient abruptly begins complaining of incredibly severe chest pain that feels like ripping in the anterior chest. He states, “I’m going to die, I know it!” The nurse alerts the provider immediately due to suspicion for which condition?

Prior to initiating routine hemodialysis for the patient with end stage renal disease (ESRD), which assessments does the nurse perform? Select all that apply.

During hourly rounds, the nurse notes a patient’s right heel has an erythematous area that is warm to the touch. The skin is intact but does not blanch with pressure. Which of the following terms is most appropriate for the nurse to use when documenting this finding?