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A nurse at a provider's office is caring for a client.

Select the 3 findings that require immediate follow-up.

Respiratory findings

Menstrual period

Vaginal spotting

Oxygen saturation

Heart rate

Temperature

Bowel sounds

Abdominal findings

Answer and Explanation

Correct Answer : A,C,H

Respiratory findings: The client has a history of asthma and now presents with slight inspiratory wheezes. Although respiratory rate and oxygen saturation are normal, wheezing indicates airway narrowing, which could worsen rapidly and needs prompt follow-up to prevent an acute asthma exacerbation.
Menstrual period: The client's menstrual period is late by two weeks, but in itself, a late period does not require immediate intervention. It is an important clinical detail but does not demand urgent follow-up unless accompanied by unstable vital signs or other concerning symptoms.
Vaginal spotting: Scant dark red spotting in a client with a late menstrual period raises concern for an ectopic pregnancy, which can be life-threatening if it ruptures. Spotting, combined with abdominal tenderness and delayed menses, demands immediate evaluation to rule out ectopic pregnancy or miscarriage.
Oxygen saturation: The oxygen saturation of 97% on room air is within the normal range for a healthy adult. There is no evidence of hypoxemia, so this finding does not require immediate follow-up despite the client’s mild wheezing.
Heart rate: The heart rate of 90/min is normal and within expected limits for adults. Although the client appears anxious, the heart rate itself does not indicate hemodynamic instability and does not require immediate intervention.
Temperature: A temperature of 37.3° C (99.1° F) is within the normal range and does not suggest active infection or systemic illness. There is no immediate concern based solely on the client’s current temperature reading.
Bowel sounds: Hyperactive bowel sounds can be associated with various conditions, including gastroenteritis, early bowel obstruction, or anxiety. While they contribute to the overall clinical picture of abdominal discomfort, they do not, on their own, necessitate immediate follow-up .
Abdominal findings: Right lower quadrant abdominal tenderness, especially in combination with spotting and late menses, is concerning for an ectopic pregnancy. The possibility of rupture or hemorrhage makes abdominal tenderness a critical finding that requires urgent evaluation.

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Correct Answer is D

Explanation

A. Decreased bowel sounds: Decreased bowel sounds are often associated with conditions like ileus, abdominal surgery, or bowel obstruction, rather than directly indicating fluid volume excess. Fluid overload typically affects the cardiovascular and respiratory systems first.

B. Urine output of 360 mL/12 hr: While this is a low urine output and could suggest dehydration or renal impairment, it is more indicative of fluid volume deficit rather than fluid volume excess. Excess fluid volume would generally be associated with adequate or increased urine output if renal function is normal.

C. Blood pressure of 100/74 mm Hg: This blood pressure reading is within normal limits for many adults and does not specifically suggest fluid overload. In cases of fluid volume excess, a client might actually exhibit elevated blood pressure due to increased circulatory volume.

D. Distended neck veins: Distended neck veins, also known as jugular venous distention, are a classic sign of fluid volume excess. They occur because increased intravascular volume causes elevated venous pressure, which becomes visible in the neck veins when the client is positioned at a 30- to 45-degree angle.

A. Encourage the client to include celery in their diet. B. Cleanse around the client's stoma with hydrogen peroxide. C. Cut the skin barrier opening 2.5 cm (1 in) larger than the stoma. D. Empty the client's pouch when it is halfway full.

Correct Answer is D

Explanation

A. Encourage the client to include celery in their diet: Celery is high in fiber and stringy, which can increase the risk of obstruction in a client with a new ileostomy. Clients should avoid foods that can block the stoma until healing is complete and they are accustomed to managing their ostomy.

B. Cleanse around the client's stoma with hydrogen peroxide: Hydrogen peroxide can damage healthy skin and tissue around the stoma. The area should be cleansed gently with warm water and mild soap, avoiding harsh or irritating substances to promote skin integrity.

C. Cut the skin barrier opening 2.5 cm (1 in) larger than the stoma: The skin barrier opening should be no more than 1/8 inch (about 0.3 cm) larger than the stoma. A larger opening exposes more skin to stoma output, increasing the risk for skin irritation and breakdown.

D. Empty the client's pouch when it is halfway full: Emptying the pouch when it is about halfway full prevents the weight from pulling on the seal, reducing the risk of leaks and protecting the skin. It also maintains client comfort and reduces the chance of pouch rupture.

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A nurse at a provider's office is caring for a client.

Select the 3 findings that require immediate follow-up.