A nurse is caring for a client who has COPD.
The following are the client’s vital signs: Temperature 38.6C (101.5° F), BP 114/86 mm Hg, Heart rate 99/min, Respiratory rate 32/min, Oxygen saturation 85% on room air.
Which three findings require follow-up?

The correct answers are Choices A, B, and C.

Choice A rationale: Passive range-of-motion exercises should be performed more frequently than once each day to maintain joint mobility, prevent contractures, and stimulate circulation. Performing them only once daily is inadequate for a client with paraplegia who is immobile.

Choice B rationale: Nonblanchable erythema is a sign of a stage 1 pressure ulcer, indicating that the skin is at risk of further breakdown and infection. Immediate intervention is required to prevent progression to more severe pressure injuries.

Choice C rationale: Plantar flexion contractures can lead to significant long-term disability and complications, such as difficulty in ambulation and pain. These contractures require intervention through more frequent range-of-motion exercises, splinting, or physical therapy to prevent worsening.

Choice D rationale: Pedal pulses that are 2+ bilaterally are within normal limits and indicate adequate peripheral circulation. This finding does not require intervention.

Choice A rationale

Pupil clarity is not typically used to assess an older adult client’s risk for falls. It is more relevant in neurological assessments.

Choice B rationale

The appearance of gait is a crucial factor in assessing an older adult client’s risk for falls. Abnormalities in gait can increase the risk of falls.

Choice C rationale

Visual fields are important in assessing an older adult client’s risk for falls. Impaired visual fields can increase the risk of falls.

Choice D rationale

Visual acuity is important in assessing an older adult client’s risk for falls. Poor visual acuity can increase the risk of falls.