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    Ati pn adult medical surgical 2023 proctored exam
    Select All That Apply

    The nurse is collecting data on the client. Which of the following findings require follow-up?Select all that apply.

    Explanation & Rationale

    A. WBC count: The WBC count is within the normal range and does not indicate infection or inflammatory worsening at this time. It does not require urgent follow-up compared with other more concerning findings in this presentation. B. Abdominal findings: High-pitched bowel sounds, pain, vomiting, and tenderness correlate with small-bowel obstruction and signal worsening motility. These findings raise concern for progression toward ischemia or perforation, so they require prompt follow-up. C. BUN level: The elevated BUN suggests dehydration from vomiting and third-spacing associated with obstruction. This may lead to worsening renal perfusion if not corrected, indicating a need for timely follow-up and fluid management. D. Potassium level: The potassium level is low and may worsen due to continued fluid losses, placing the client at risk for arrhythmias. Correction and monitoring are important, especially in the context of dehydration and tachycardia. E. Blood pressure: The low blood pressure and elevated pulse indicate possible hypovolemia from fluid shifts and decreased intake. This hemodynamic change requires intervention to prevent further decline and maintain organ perfusion. F. Breath sounds: Breath sounds are clear bilaterally and show no signs of respiratory involvement. They are not concerning in relation to the client’s current abdominal pathology and do not need immediate follow-up.

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