A nurse is assisting with the care of a client.

Select the 3 findings that require immediate follow up

Heart rate

Pedal pulses

Breath sounds

Abdominal dressing

Respiratory rate

Oxygen saturation

Answer and Explanation

Correct Answer : A,D,E

A. Heart rate: The increase from 88/min to 110/min indicates tachycardia, which can be an early sign of hypovolemia, infection, or sepsis. When combined with hypotension and fever, this finding suggests possible postoperative complications requiring urgent evaluation.

B. Pedal pulses: Bilateral pedal pulses remain 2+, indicating adequate peripheral perfusion at this time. This finding is stable and does not suggest acute circulatory compromise requiring immediate follow-up.

C. Breath sounds: Breath sounds are clear and unchanged from admission, suggesting no current pulmonary complication such as atelectasis or pneumonia. This finding does not indicate an urgent problem.

D. Abdominal dressing: A sudden increase to a large amount of serosanguinous drainage after the client felt something “pop” raises concern for wound dehiscence or possible evisceration. This is a surgical emergency requiring immediate assessment and intervention.

E. Respiratory rate: The respiratory rate has increased from 18/min to 24/min, indicating tachypnea. This may reflect pain, infection, or developing sepsis and warrants prompt follow-up in the postoperative client.

F. Oxygen saturation: Oxygen saturation remains within an acceptable range at 95% on room air. Although it should continue to be monitored, it does not currently indicate acute respiratory compromise.

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Correct Answer is D

Explanation

A. Gown: Gowns are typically used to protect against contact with infectious body fluids or contaminated surfaces. Tuberculosis is primarily transmitted via airborne droplets, so gowns are not required for routine care of a client with suspected TB.

B. Gloves: Gloves protect against direct contact with infectious materials or bodily fluids. While gloves may be used during procedures involving secretions, they are not the primary protective equipment for preventing inhalation of airborne TB particles.

C. Dosimeter badge: Dosimeter badges monitor exposure to ionizing radiation and are irrelevant in the context of airborne infectious diseases like tuberculosis. Wearing a dosimeter does not protect against TB transmission.

D. N95 respirator: An N95 respirator is specifically designed to filter airborne particles, including Mycobacterium tuberculosis. Nurses must wear an N95 respirator when entering the room of a client with suspected or confirmed TB to prevent inhalation of infectious droplets.

A. Deliver 2 L of oxygen via partial nonrebreather mask B. Give epinephrine intramuscularly C. Notify the radiology department. D. Administer diazepam PO.

Correct Answer is B

Explanation

A. Deliver 2 L of oxygen via partial nonrebreather mask: While supplemental oxygen may support oxygenation, it does not treat the underlying life-threatening allergic reaction. Oxygen alone is insufficient for anaphylaxis and should not delay definitive treatment.

B. Give epinephrine intramuscularly: Epinephrine is the first-line treatment for anaphylaxis and rapidly counteracts airway constriction, hypotension, and vascular permeability. Intramuscular administration in the mid-outer thigh provides rapid absorption and is essential to prevent respiratory compromise and shock.

C. Notify the radiology department: Notifying radiology is unrelated to the acute management of an allergic reaction. Immediate intervention to secure the airway and treat anaphylaxis takes priority over nonessential notifications.

D. Administer diazepam PO: Diazepam is an anxiolytic and has no role in managing anaphylaxis or airway obstruction. It does not reverse histamine-mediated effects and would delay critical emergency treatment.

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A nurse is assisting with the care of a client. Select the 3 findings that require immediate follow up

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A nurse is assisting with the care of a client.

Select the 3 findings that require immediate follow up