A nurse is assisting in the care of a client who has a continuous enteral feeding. Exhibit 1 Exhibit 2 Nurses Notes 1100: Client is receiving 60 mL/hr of continuous feeding via g-tube. Site is clean and dressing intact. Bilateral breath sounds are clear. Heart rate is regular. Bowel sounds are present in all quadrants. Abdomen is soft and non-tender. Client’s bed elevated to 30° degrees. Client is oriented to person, place, and time. Client has +2 pedal pulses. Capillary refill is less than 2 seconds. 1500: Gastric residual 520 mL. pH is 7.2. Client is coughing intermittently and is non-productive. Bilateral breath sounds with fine crackles heard in bases. Select the “3” findings that require notification of the charge nurse. Bowel sounds Lung sounds Client cough Gastric residual Blood pressure Capillary refill