# The charge nurse reviews the unit census. Which client findings require immediate follow-up? Highlight the findings that the nurse should address first.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=556755&lang=en  
> language: en  
> subject: Assignment/Delegation/Supervision  
> category: MOC

## Question

The charge nurse reviews the unit census. Which client findings require immediate follow-up? Highlight the findings that the nurse should address first.

| Client | Current finding |
| --- | --- |
| Client 2 | The new colostomy is pink and moist with a small amount of serosanguineous drainage. |
| Client 1 | Four hours after thyroid surgery, a new high-pitched sound is heard during inspiration. |
| Client 4 | Oxygen saturation is 90% on the prescribed oxygen, within the documented target range. |
| Client 3 | The right arm suddenly drifts downward and speech becomes slurred during conversation. |
| Client 5 | Bruising remains localized around the repaired hip and has not enlarged since morning. |
| Client 7 | Abdominal pain decreased from 7 to 3 after the prescribed analgesic was given. |
| Client 6 | No thrill is felt over the arteriovenous fistula before the scheduled dialysis treatment. |
| Client 9 | Urine output is 550 mL after intravenous furosemide, and breathing is less labored. |
| Client 8 | A client with sickle cell disease has a temperature of 38.6 °C and a new cough. |

## Explanation

New airway noise, sudden focal neurologic change, absent dialysis-access flow, and fever with sickle cell disease can rapidly threaten life or treatment access. Prioritize acute deterioration over expected recovery findings.

## In-depth explanation

Quick answer
Follow up immediately on the new inspiratory noise, sudden arm drift with slurred speech, absent fistula thrill, and fever with a new cough. Each finding represents an acute threat to airway, brain perfusion, dialysis access, or infection control.

Why this is correct
A high-pitched inspiratory sound after thyroid surgery may precede airway obstruction. Sudden unilateral weakness and speech change are stroke warnings that need rapid action.[2] An absent dialysis-access thrill suggests loss of blood flow, while fever in sickle cell disease can signal a dangerous infection. These are new changes, not stable baseline findings.

Easy analogy or mental picture
Picture four alarm panels: airway, brain, access flow, and infection. A new alarm on any panel outranks a routine status light. The picture only organizes priority; the nurse still performs a focused assessment and follows the appropriate emergency process.

Memory hook
New airway, new neuro, no flow, new fever: see these clients first.

NCLEX decision rule
When several clients compete for attention, think new threat before expected recovery; check airway, neurologic status, circulation or access, and infection risk before routine comfort or discharge tasks.

Why the other choices are wrong
A pink moist stoma, oxygen saturation within an ordered COPD target, expected bruising, pain improved by treatment, and brisk urine output after a diuretic all need continued monitoring. None shows the same abrupt threat as the selected findings.References

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]CDC: Signs and Symptoms of StrokeCenters for Disease Control and Prevention

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