Select the 4 assessment findings that require immediate follow up.
Explanation & Rationale
A. Blood pressure 115/76 mm Hg: This blood pressure is within normal limits for a young adult and does not indicate hemodynamic instability. While monitoring is important, it does not require immediate intervention compared with other acute findings. B. Vomiting small amounts of green bile: Bilious vomiting can indicate a gastrointestinal obstruction or severe irritation of the gastrointestinal tract. In combination with acute abdominal pain, this finding requires immediate evaluation to prevent complications such as bowel ischemia or perforation. C. Radial and pedal pulses 2+: Peripheral pulses are normal and indicate adequate perfusion. Although continuous monitoring is appropriate, this finding does not require immediate intervention. D. Feels anxious: Anxiety is a common response to acute pain or illness but does not pose an immediate threat to physiological stability. It should be addressed, but it is not a priority over life-threatening or potentially worsening conditions. E. Heart rate 121 beats/minute: Tachycardia may indicate pain, dehydration, or early hypovolemia. In the context of acute abdominal pain and vomiting, it signals potential circulatory compromise and requires prompt follow-up. F. Respirations 28 breaths/minute with shallow breathing: Tachypnea with shallow breathing may reflect pain, metabolic acidosis, or early respiratory compromise. It requires immediate assessment and intervention to ensure adequate oxygenation and ventilation. G. Severe abdominal pain in right lower quadrant: Severe, acute right lower quadrant pain suggests a potentially serious condition such as appendicitis, perforation, or obstruction. Immediate evaluation is required to prevent worsening of the condition or complications. H. Temperature 100.8° F (38.2° C) orally: Mild fever may indicate early infection or inflammation but is not immediately life-threatening. It should be monitored and managed as part of ongoing assessment. I. Capillary refill 2 seconds: Capillary refill is within normal limits, indicating adequate peripheral perfusion. Immediate follow-up is not required based on this finding alone.