A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)

A. The heart rate has increased from 92/min on Day 1 to 108/min on Day 2. This significant increase warrants immediate follow-up as it may indicate pain, anxiety, or an underlying physiological issue such as hemorrhage, infection, or cardiac complications.

D. The temperature has increased from 36.4°C (97.5°F) on Day 1 to 37.2°C (98.9°F) on Day 2. While this increase is within a relatively normal range, it is approaching a fever range (> 38°C or 100.4°F) and warrants further evaluation to determine if there is an underlying infection or inflammation.

B. The oxygen saturation remains relatively stable, from 95% on Day 1 to 96% on Day 2. While it is important to monitor oxygen saturation, the minimal change does not indicate an immediate concern. However, it should still be monitored closely for any further decrease.

C. Edema is not directly mentioned in the provided data. While edema can be indicative of various health issues, there is no evidence in the given information to suggest its presence or severity as a concern requiring immediate follow-up.

E. Urine color is not provided in the given data. While changes in urine color can indicate dehydration or other health issues, it is not mentioned in the assessment findings and therefore not a factor for immediate follow-up based on the information provided.

F Pedal pulses were noted as +2 on Day 1, indicating that they were present and normal. Unless there is a significant change in pedal pulses or signs of vascular compromise, such as decreased or absent pulses, there is no immediate need for follow-up based on the given information.

A. Checking capillary refill distal to the cast helps assess peripheral circulation and nerve function. A decrease in capillary refill time or other signs of compromised circulation (such as coolness, pallor, or numbness) could indicate a complication like compartment syndrome, which requires immediate intervention.

B. Performing range of motion exercises is important for promoting joint mobility and preventing stiffness, but it is not the priority immediately after the cast application.

C. Educating the client about cast care is important for promoting healing and preventing complications, but it is not the priority immediately after the cast application.

D. Managing pain is important for the client's comfort and well-being, but it is not the priority immediately after the cast application.