Patient Data Exhibits Select the 4 assessment findings that require immediate follow up.
Explanation & Rationale
A. Severe abdominal pain in the right lower quadrant: This could indicate appendicitis, a surgical emergency, or another acute abdominal condition requiring immediate intervention. The sudden onset and severe nature of pain are concerning. B. Blood pressure 115/76 mm Hg: This is within normal limits and does not indicate immediate instability. C. Capillary refill 2 seconds: This indicates adequate peripheral perfusion and is not an urgent concern. D. Radial and pedal pulses 2+: Normal peripheral pulses do not require immediate follow-up. E. Temperature 100.8° F (38.2° C): Fever suggests an inflammatory or infectious process, such as appendicitis or another intra-abdominal infection. F. Respirations 28 breaths/minute with shallow breathing: Increased respiratory rate and shallow breathing may indicate pain-related distress or developing peritonitis, a life-threatening complication of appendicitis. G. Feels anxious: Anxiety may be a response to pain but is not an immediate concern requiring urgent intervention. H. Heart rate 121 beats/minute: Tachycardia could be a response to pain, infection, or developing sepsis, which requires urgent evaluation. I. Vomiting small amounts of green bile: While bile-stained emesis can indicate an obstruction, other findings (pain, fever, tachycardia, and respiratory distress) are higher priority.