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A nurse is caring for a client in the emergency department (ED).

Exhibits

Select the 4 assessment findings on day 2 that require immediate follow-up.

A.

Heart rate

B.

Oxygen saturation

C.

Edema

D.

Temperature

E.

Urine color

F.

Pedal pulses

Answer and Explanation

Correct Answer : A,C,E,F

A. Heart rate: The increased heart rate (108/min) may indicate a developing complication such as hypovolemia or pain. This requires monitoring as it could signal deteriorating status.

B. Oxygen saturation: The SpO₂ level is stable at 96%, which is within an acceptable range and does not indicate an immediate concern.

C. Edema: The increase in sacral and iliac region edema (2+) from day 1 to day 2 suggests worsening swelling and possible fluid accumulation, which could be affecting blood flow and leading to circulatory issues.

D. Temperature: The temperature remains within a normal range, so it does not require immediate intervention.

E. Urine color: Dark, reddish-brown urine suggests possible bleeding or rhabdomyolysis, both of which require immediate follow-up to prevent further complications and assess kidney function.

F. Pedal pulses: The change to 1+ pedal pulses bilaterally and the delayed capillary refill time (6 seconds) indicate reduced perfusion to the lower extremities, which may suggest compromised circulation or increased edema affecting blood flow.


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Related Questions

Correct Answer is A

Explanation

A. A GCS score of 3 for eye opening indicates that the client does not open their eyes spontaneously, while a score of 5 for best verbal response suggests that they can respond verbally, likely indicating that they can open their eyes when spoken to or when commanded. This conclusion aligns with the score of 5 for verbal response, which indicates a higher level of responsiveness.

B. This option is incorrect because a score of 5 for best verbal response indicates that the client can produce vocal sounds, meaning they are capable of making verbal responses.

C. While the eye opening score of 3 suggests significant impairment, the overall GCS score of 13 (3 + 5 + 5) does not support the conclusion that the client is completely unconscious. The presence of verbal and motor responses indicates some level of consciousness.

D. This conclusion is incorrect because a score of 5 for best motor response suggests that the client can follow commands and respond to stimuli, which is inconsistent with being unable to follow commands.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"D"},"E":{"answers":"A"}}

Explanation

Platelet count: Low platelets (135,000/mm³) increase bleeding risk as they are essential for clot formation.

Hemoglobin: A hemoglobin level within the low normal range could increase the risk of hypoxemia, particularly in the perioperative period when oxygen demand may be higher.

INR: Elevated INR (1.5) indicates increased bleeding risk due to prolonged clotting time.

Atrial fibrillation: Increases the risk of DVT due to irregular heart rhythms, which can lead to blood pooling and clot formation.

RBC count: A low RBC count contributes to the risk of hypoxemia as there are fewer red blood cells available to transport oxygen.

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