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 C

Explanation

A. Assist the client with dangling off the side of the bed: While mobilization can help prevent complications such as atelectasis or thromboembolism, it does not address the immediate concern of a possible postoperative infection indicated by the elevated temperature.

B. Obtain a prescription to check the client's CBC: Ordering a CBC can help identify infection or inflammation, but it is a diagnostic action that follows initial assessment. Immediate assessment of potential sources of infection takes priority.

C. Check the condition of the client's surgical incision: Assessing the surgical site is the first action because an incision can be a primary source of infection in postoperative clients. Early identification of redness, drainage, or other signs of infection allows prompt intervention.

D. Instruct the client to breathe deeply and cough: Deep breathing and coughing are important for preventing respiratory complications, but they do not address the urgent need to assess for infection, which is indicated by the elevated temperature.

A. Moderate lochia rubra on the pad B. Nipple tenderness with breastfeeding C. Hemorrhoids on the rectal area D. Calf edematous and tender

Correct Answer is D

Explanation

A. Moderate lochia rubra on the pad: Moderate lochia 24 hours postpartum is considered a normal finding as the uterus continues to shed the lining. It typically appears bright red and gradually decreases over the following days, so it does not require immediate reporting.

B. Nipple tenderness with breastfeeding: Nipple tenderness is common in the early postpartum period due to breastfeeding, especially if the latch is not optimal. While it should be addressed to prevent complications, it is not an urgent finding requiring immediate reporting.

C. Hemorrhoids on the rectal area: Hemorrhoids are a frequent postpartum occurrence, often resulting from vaginal delivery or straining during labor. They are uncomfortable but not emergent, so they do not need immediate reporting.

D. Calf edematous and tender: A calf that is swollen, edematous, and tender may indicate a deep vein thrombosis (DVT), which is a potentially life-threatening postpartum complication. This finding requires immediate reporting to the primary RN for timely assessment and intervention.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A nurse is assisting with the care of a client.

Select the 3 findings that require immediate follow up