A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility.

Admission Assessment 1400:

Client's history includes cigarette smoking for 50 years but quit 3 years ago, Parkinson's disease, and anxiety. Yesterday, client reported "feeling bad." Client is alert and oriented to self, reports upper chest discomfort, and is coughing up thick clear sputum.

Select the 3 findings that require immediate follow-up.

The four findings that require follow-up are B, C, E, and F.

Rationale:

1. Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires followup or not.
2. Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
3. Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
4. Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
5. Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
6. Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.

Choice A rationale:

Repositioning the NG tube is not the appropriate action for hyperosmolar dehydration. This condition occurs due to an excessive concentration of solutes in the body, leading to a decrease in intracellular water. Repositioning the tube would not address the hyperosmolarity issue.

Choice B rationale:

Increasing the rate of formula delivery may exacerbate the problem by introducing more concentrated formula into the client's system, worsening hyperosmolarity. This choice can lead to further dehydration and electrolyte imbalances.

Choice C rationale:

Adding water to the formula is the correct action in this scenario. Hyperosmolar dehydration requires dilution of the concentrated formula to reduce the osmolarity. By adding water to the formula, the nurse can decrease the concentration of solutes, helping to rehydrate the client effectively.

Choice D rationale:

Switching to a lactose-free formula is not the appropriate intervention for hyperosmolar dehydration. The issue lies in the concentration of the formula, not in its lactose content. Adding water is the more suitable and direct approach to address the problem.