A nurse is caring for a client.

Vital Signs.

1600: Nurses' Notes.

Temperature 37.6°C (99.7°F). Blood pressure 110/58 mm Hg. Heart rate 72/min.

Respiratory rate 18/min.

Pulse oximetry 98% on room air.

1630: Temperature 37.5°C (99.5°F). Blood pressure 78/52 mm Hg. Heart rate 112/min.

Respiratory rate 26/min.

Pulse oximetry 92% on room air.

1600: Antibiotic administered as prescribed.

Bilateral breath sounds clear and present throughout.

1630: Client reports itching on the chest and has urticaria over the chest and trunk.

Client states they are having difficulty swallowing and feel as if there is a lump in their throat.

Bilateral breath sounds with scattered wheezing heard throughout.

Vital Signs.

Nurses' Notes.

Medication Administration Record.

Cefaclor 500 mg PO q8h.

Select the 3 findings that require immediate follow-up.

Choice A rationale:

Serosanguineous drainage noted on the abdominal dressing is a common finding in the early postoperative period. It is a mixture of clear and bloody drainage and is often seen after surgery. This does not typically require immediate reporting unless it becomes excessive or changes significantly. The nurse can continue to monitor and assess the situation.

Choice B rationale:

Postoperative laboratory results of Hgb 15% and Hct 40% are within the normal range for most adults, and there is no immediate need to report these results to the provider. These values suggest that the client's hemoglobin and hematocrit levels are within an acceptable range, indicating adequate oxygen-carrying capacity.

Choice C rationale:

The client's urine output has been 50 mL since surgery, which is significantly decreased and could indicate a potential issue with renal function or fluid balance. This should be reported to the provider, as it may be indicative of kidney impairment, dehydration, or other postoperative complications.

Choice D rationale:

The client's pain level decreasing after the administration of morphine is an expected response to pain management interventions. There is no need to report this information to the provider unless the pain relief is inadequate or the client experiences adverse effects. Pain management is an essential part of postoperative care, and successful pain reduction is a positive outcome.

The correct answer is to select the following three findings that require immediate follow-up:C. Urticaria,D. Blood pressure at 1630, andE. Report of dysphagia.

Choice A rationale:

“Breath sounds at 1600.” The breath sounds at 1600 were clear and present throughout, which is a normal finding and does not require immediate follow-up.

Choice B rationale:

“Temperature.” The temperature readings at both 1600 and 1630 are slightly elevated but not critically high. This does not require immediate follow-up compared to the other findings.

Choice C rationale:

“Urticaria.” The presence of urticaria (hives) indicates an allergic reaction, which can potentially escalate to a more severe reaction such as anaphylaxis.Immediate follow-up is necessary to prevent further complications.

Choice D rationale:

“Blood pressure at 1630.” The blood pressure at 1630 is significantly lower (78/52 mm Hg) compared to the earlier reading (110/58 mm Hg).This hypotension could indicate a serious reaction to the medication or another underlying issue that requires prompt attention.

Choice E rationale:

“Report of dysphagia.” The client’s report of difficulty swallowing and feeling a lump in their throat is concerning for a potential airway obstruction or severe allergic reaction, such as anaphylaxis.This symptom requires immediate follow-up to ensure the client’s airway remains open and to provide necessary interventions.