The nurse is caring for a client. Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Nurses' Notes 1900: Client reports sudden onset of dyspnea and chest discomfort. Client transferred back to bed. Client is awake and orientated x4. Client states, "I just feel like something is really wrong." Client is tachypneic and appears in distress. Crackles heard in bilateral lungs. S3 and S4 heart sounds noted. Bilateral pedal pulses are +1. Surgical site is dressed, dry, and intact. Vitals Signs 1900: Temperature 38.9°C (102° F) Heart rate 112/min Respiratory rate 34/min Blood pressure 144/72 mm Hg Oxygen saturation 92% on 2 L/min via nasal cannula
Explanation & Rationale
Rationale for Correct Answers: Sudden onset of dyspnea and chest discomfort: Any sudden respiratory distress or chest pain post-surgery is a red flag for pulmonary embolism or myocardial infarction. Client is tachypneic and appears in distress: Rapid breathing and physical signs of distress indicate the client is struggling to maintain adequate ventilation and oxygenation. S3 and S4 heart sounds noted: The presence of extra heart sounds can indicate acute heart failure or ventricular strain, which may occur if the heart is struggling against a pulmonary obstruction. Respiratory rate 34/min: This is significantly above the normal range (12–20/min) and confirms severe tachypnea. Oxygen saturation 92% on 2 L/min via nasal cannula: Despite receiving supplemental oxygen, the saturation is below the expected 95–100%, indicating impaired gas exchange. Rationale for Incorrect Answers: Client is awake and orientated x4: While positive, this is a baseline neurologic expectation and does not represent an acute deterioration in this context. Bilateral pedal pulses are +1: While slightly diminished, the fact that they are bilateral and present suggests peripheral perfusion is occurring, though this should be monitored relative to the client's baseline. Blood pressure 144/72 mm Hg: While slightly elevated, this is relatively stable compared to the 0900 reading (142/68) and is not as immediate a priority as the respiratory distress.