A nurse is caring for a 60-year-old male client in a provider’s clinic. Exhibits Click to select all the findings that require immediate follow-up.
Explanation & Rationale
Choice A rationale: This temperature indicates a low-grade fever. Although not immediately life-threatening, it may suggest an underlying infection or inflammation that requires attention, especially given the client's other symptoms and elevated WBC count. Choice B rationale: A heart rate of 97/min is slightly elevated but within the upper range of normal limits (60–100 bpm). This finding alone does not necessarily require immediate follow-up, especially without more severe symptoms. Choice C rationale: A respiratory rate of 24/min is above the normal range (12–20 breaths/min) and may indicate respiratory distress or an underlying condition. The elevated rate, combined with low oxygen saturation, requires prompt follow-up. Choice D rationale: The blood pressure reading of 135/73 mmHg is considered prehypertensive (normal range: <120/80 mmHg). While monitoring is essential, it does not immediately require follow-up in the context of other, more urgent issues. Choice E rationale: An oxygen saturation of 88% on room air is significantly below the normal range (95–100%) and indicates hypoxemia. This requires immediate attention to address potential respiratory failure or other underlying causes. Choice F rationale: Pain rated at 6 on a 0 to 10 scale is concerning but requires contextual evaluation. While high pain levels warrant attention, they are not immediately life-threatening compared to hypoxemia and respiratory distress.