Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.
Explanation & Rationale
Choice A rationale: Blood pressure of 90/79 mm Hg with a pulse pressure less than 40 mm Hg is concerning because it indicates hypotension and a narrowed pulse pressure, which can be signs of significant internal bleeding or shock. This requires immediate medical attention to stabilize the client's condition. Choice B rationale: Oxygen saturation of 100% on 40% FiO₂ is not a critical finding that requires immediate reporting. The client is receiving sufficient oxygen, and the saturation level indicates adequate oxygenation. Choice C rationale: Heart rate of 128 beats/minute, sinus tachycardia is an important finding because tachycardia can indicate a response to pain, anxiety, hypovolemia, or shock. It needs to be reported to assess and address the underlying cause. Choice D rationale: CT scan findings of liver and spleen lacerations with blood in the peritoneum are critical because they indicate significant internal injuries and active bleeding. This requires immediate surgical intervention and close monitoring.