Which chart entry requires follow up by the nurse?

• A. BP 130/82 mm Hg left arm, lying. Client reports experiencing postoperative pain as 7 on a scale of 0 to 10. Prescribed analgesic administered and will re-evaluate BP in 30 min.
• B. Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall.
• C. saO2 93% left index finger, client, sleeping, nasal O2 dislodged. Nasal O2 readjusted and saO2 increased to 95%.
• D. Respiratory rate 18/min the observation, client sitting in chair.

Answer: (B)

When deciding which chart entry needs follow-up, focus on signs that suggest a patient may be unstable and require closer monitoring. A pulse of 116/min while the patient is standing after ambulating is a concerning change in heart rate, especially in the immediate postoperative period. Standing and activity can reveal orthostatic responses, but a heart rate this high raises questions about dehydration, pain control adequacy, blood loss, infection, anemia, or cardiopulmonary issues. This scenario calls for prompt follow-up: re-check vitals in multiple positions (lying, sitting, standing), assess for symptoms such as dizziness, chest pain, or shortness of breath, review fluid status and analgesia, and consider notifying a provider if the tachycardia persists or is accompanied by other concerning signs.

The other entries describe issues that have been addressed or are within expected limits: planned re-evaluation after analgesia is a routine step; oxygen saturation was corrected after readjusting the nasal collar and has improved; respiratory rate is normal and stable in a comfortable position.