A nurse assisting with the care of a client who is admitted to the medical-surgical unit.

The nurse is reviewing the client's laboratory findings and vital signs.

Select the 5 findings that require immediate follow-up.

A. Encourage prolonged dangling before ambulation.
Prolonged dangling is not necessary for this client, who is already ambulating independently. Extended dangling may increase the risk of orthostatic hypotension without providing significant benefits.

B. Administer an enema.
An enema is not the first-line intervention for postoperative constipation. The client has had a bowel movement, albeit small and painful, so increasing fluids and noninvasive measures like a sitz bath should be attempted first.

C. Encourage oral fluid intake.
Adequate hydration helps soften stool and prevent constipation, a common postoperative concern. The client’s fluid intake should be increased to support bowel function and improve urinary output.

D. Irrigate indwelling catheter with 500 mL of fluid.
The client has pink urine but is maintaining an adequate output of 100 mL/hr. Routine catheter irrigation is unnecessary unless there is evidence of obstruction, such as decreased urine flow or clot formation.

E. Assist the client with a sitz bath.
A sitz bath can provide comfort by promoting relaxation of perineal muscles, reducing pain during bowel movements, and improving circulation to the surgical site, which may aid healing.

A) Measure the client’s vital signs: The first priority after a fall is to assess the client's physical condition to determine if any immediate harm or injury has occurred. Taking the vital signs allows the nurse to assess for signs of shock, internal injury, or other complications that could require urgent intervention. This step should be done before notifying the provider or completing paperwork.

B) Notify the client's provider: While notifying the provider is important, it is not the first step. The nurse's priority is to assess the client’s condition and ensure they are stable. Once the client’s condition has been assessed, the provider can be notified if necessary.

C) Complete an incident report: An incident report should be completed after the client’s immediate needs are addressed. While documentation of the fall is important, the priority is the client’s safety and well-being. The nurse should first evaluate and stabilize the client before focusing on administrative tasks like the incident report.

D) Document the fall in the client's medical record: Although documentation is essential, the first priority should always be assessing and stabilizing the client. Once the client’s safety is ensured, then documenting the event and any findings is appropriate.