A nurse in a walk-in clinic is caring for a client.

Which of the following six findings should the nurse report to the provider? Select the 6 findings that require immediate follow-up.

1300:

• Temperature 39.1° C (102.4° F)
• Heart rate 115/min
• Respiratory rate 30/min
• Blood pressure 99/58 mm Hg
• Oxygen saturation 93% on room air

1330:

• Temperature 39.2° C (102.5° F)
• Heart rate 118/min
• Respiratory rate 28/min
• Blood pressure 91/52 mm Hg
• Oxygen saturation 95% on 2 L/min nasal cannula
• Heart rate
• Skin turgor
• Temperature
• Heart sounds
• Blood pressure
• COVID test results
• Orientation
• Lung sounds

A nurse in a health clinic is caring for a client. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurse's Notes

0930:

• Client reports 2-day history of urinary frequency, burning on urination, and lower back and suprapubic pain. States developed a fever of 39.3°C (102.8°F) this morning.
• Oriented x-4, answers questions appropriately.
• S1, S2, on auscultation. Lungs clear on auscultation.
• Bowel sounds x 4 quadrants active, denies nausea or vomiting.

0945:

• Request client provide clean-catch urinary specimen for testing.
• Urinalysis results reviewed.

Vital Signs 0930:

• Temperature: 39.3°C (102.8°F)
• Heart rate: 113/min
• Respiratory rate: 24/min
• Blood pressure: 122/68 mm Hg
• Oxygen saturation: 96% on room air

Diagnostic Results 1030:

Urinalysis

• Appearance: Cloudy
• Color: Amber yellow
• Odor: Aromatic
• pH: 8.0 (Reference: 4.6 to 8.0)
• Protein: 6.5 mg/dL (Reference: 0 to 8 mg/dL)
• Specific gravity: 1.035 (Reference: 1.005 to 1.030)
• Leukocyte esterase: Positive
• Nitrites: Present
• Ketones: None
• Bilirubin: None

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