Question

A nurse has received a report on a client who is being admitted to the emergency department. Select the 3 findings that require follow-up by the nurse.

A. Respiratory rate of 18 breaths/minute
B. Blood pressure 90/50 mmHg
C. Capillary refill time less than 2 seconds
D. Urine output of 30 mL/hour
E. Temperature of 99.5°F
F. Oxygen saturation of 97%

Answer 1

The nurse should follow-up on the findings of low blood pressure (90/50 mmHg), low urine output (30 mL/hour), and slightly low respiratory rate (18 breaths/minute).

Step-by-step explanation:

Among the findings that require follow-up by the nurse are:

1. Blood pressure 90/50 mmHg: A blood pressure reading of 90/50 mmHg indicates hypotension, which may be a sign of inadequate blood flow to the organs. This finding requires further evaluation and intervention.
2. Urine output of 30 mL/hour: A urine output of 30 mL/hour is considered low and may indicate compromised kidney function. The nurse should investigate the cause and take appropriate actions.
3. Respiratory rate of 18 breaths/minute: While a respiratory rate of 18 breaths/minute falls within the normal range, it is on the lower end. The nurse should assess for any signs of respiratory distress or complications.