A nurse on a medical-surgical unit is assisting in the care of a male client.

Exhibits

Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.

A. Close the doors to the room and to the bathroom: This helps to contain the smoke but does not address the immediate danger of the smoke.
B. Assist the client to a nearby common area: This is correct as ensuring the safety of the client is the top priority. The client should be moved to a safer location away from the smoke.
C. Activate the fire alarm system: This is important for alerting others to the fire but does not directly address the immediate danger to the client.
D. Use a fire extinguisher at the source of the smoke: This can be done after ensuring the client's safety, as the primary concern is to remove the client from potential harm.

A. Temperature: The temperature remains stable and within normal limits. A postoperative temperature range of 36.3° C (97.3° F) to 36.4° C (97.5° F) is not indicative of infection or other complications at this time.

B. Heart rate: The heart rate has increased from 84/min to 104/min, indicating sinus tachycardia. This could be a compensatory response to decreased blood volume or another underlying issue, necessitating further assessment.

C. Skin findings: The skin findings are described as warm and dry, which is normal. No abnormalities are noted, so this does not require follow-up.

D. Respiratory rate: The respiratory rate has increased slightly to 24/min but is not significantly abnormal. This may not be a priority for follow-up unless other symptoms are present.

E. Oxygen saturation: The oxygen saturation is within normal limits (96% on room air), suggesting adequate oxygenation. No immediate concerns are evident based on this measurement.

F. Blood pressure: The blood pressure has dropped from 106/74 mm Hg to 88/54 mm Hg, indicating possible hypotension. This drop could signal hypovolemia or bleeding, requiring prompt follow-up to investigate the cause.

G. Urinary output: The urinary output of 110 mL over 6 hours is low, which might indicate dehydration or renal issues. Monitoring and addressing this finding are important to ensure adequate fluid balance and kidney function.