A nurse is caring for an older adult client in the emergency department (ED). Select the 4 assessment findings on day 2 that require immediate follow-up.
Explanation & Rationale
Choice A rationale: Oxygen saturation of 96% remains within normal range, indicating adequate oxygenation and no immediate respiratory compromise requiring urgent intervention. Choice B rationale: Edema progression to 2+ in sacral and iliac region suggests worsening tissue injury or internal bleeding, requiring prompt evaluation to prevent circulatory compromise. Choice C rationale: Temperature of 37.2°C is only mildly elevated, consistent with stress or minor inflammation, not indicative of infection or systemic instability requiring urgent follow-up. Choice D rationale: Dark, reddish-brown urine indicates hematuria or myoglobinuria, suggesting trauma-related bleeding or rhabdomyolysis, requiring immediate follow-up to prevent renal damage or systemic complications. Choice E rationale: Pedal pulses diminished to 1+ with cool extremities and delayed capillary refill indicate impaired perfusion, requiring urgent follow-up to prevent ischemia and tissue necrosis. Choice F rationale: Heart rate of 108/min indicates tachycardia, which may reflect pain, hypovolemia, or early shock, requiring immediate follow-up to prevent progression to circulatory collapse.