A nurse is assisting with the care of a client. Nurses' Notes. Day 1: Admitted to medical-surgical unit following exploratory laparotomy for a ruptured appendix. Alert and oriented to. person, place, and time. Bilateral breath sounds clear and present throughout. Bilateral pedal pulses 2+. Abdominal dressing with small serosanguinous drainage. Day 5: Alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Bilateral pedal pulses 2+. Client reports feeling something "popped" at the abdominal incision after coughing. Abdominal dressing with large amount of serosanguinous drainage. Select the 3 findings that require immediate follow-up.

Choice A rationale: Pedal pulses are a measure of peripheral circulation. A 2+ rating is considered normal, indicating a brisk, expected response. There’s no change in the client’s pedal pulses from Day 1 to Day 5, so this doesn’t require immediate follow-up. Choice B rationale: Oxygen saturation is not mentioned in the Nurses’ Notes, so we cannot provide a rationale for this choice. Choice C rationale: Breath sounds are an important indicator of respiratory health. The client’s breath sounds are clear and present throughout on both Day 1 and Day 5, which is normal and doesn’t require immediate follow-up. Choice D rationale: Respiratory rate is not mentioned in the Nurses’ Notes, but any significant change in respiratory rate could indicate a problem such as infection or pain, and would require immediate follow-up. Choice E rationale: The abdominal dressing shows a large amount of serosanguinous drainage on Day 5, compared to a small amount on Day 1. This could indicate a complication such as infection or dehiscence (separation of the wound), especially since the client reported feeling something “popped” at the incision site after coughing. This requires immediate follow-up. Choice F rationale: Heart rate is not mentioned in the Nurses’ Notes, but any significant change in heart rate could indicate a systemic response to factors such as pain or infection, and would require immediate follow-up. In summary, while pedal pulses and breath sounds remain normal, the change in the abdominal dressing and potential changes in respiratory rate and heart rate (though not documented here) should be addressed immediately to ensure the client’s health and recovery.