A nurse is assisting with the care of a client who is admitted to the medical-surgical unit. Exhibits The nurse is reviewing the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.
Explanation & Rationale
A. Current medications. The client is taking ibuprofen 800 mg three times daily, which is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause gastric mucosal injury, leading to peptic ulcers and gastrointestinal bleeding. Given the client's symptoms and history of dark, tarry stools, the use of NSAIDs requires immediate follow-up to prevent further complications. B. Respiratory rate. The client’s respiratory rate is 18/min, which is within the normal range (12 to 20/min). This finding does not require immediate follow-up. C. WBC count. The WBC count is 6,700/mm³, which falls within the normal range (5,000 to 10,000/mm³). There is no indication of an active infection or leukocytosis requiring urgent intervention. D. Heart rate. The heart rate is 118/min, which is elevated and suggests tachycardia. This could be a compensatory response to hypovolemia from gastrointestinal bleeding. Immediate follow-up is necessary to prevent hemodynamic instability. E. Stool results. The stool test is positive for occult blood, indicating gastrointestinal bleeding. This finding requires immediate follow-up to determine the severity of bleeding and prevent further blood loss. F. Temperature. The client’s temperature is 37.5°C (99.5°F), which is within the normal range. There is no indication of fever or infection, so this does not require immediate intervention. G. Blood pressure. The blood pressure is 90/50 mm Hg, which is low and may indicate hypovolemia due to gastrointestinal blood loss. Hypotension combined with tachycardia is a concerning sign that requires urgent intervention. H. Hemoglobin and hematocrit. The hemoglobin (9.1 g/dL) and hematocrit (27%) are low, suggesting anemia likely due to chronic blood loss. This requires immediate follow-up to assess for continued bleeding and the need for interventions such as fluid resuscitation or blood transfusion.