A nurse is assisting with the care of a client. Nurses' Notes. Day 1: Admitted to medical-surgical unit following exploratory laparotomy for a ruptured appendix. Alert and oriented to. person, place, and time. Bilateral breath sounds clear and present throughout. Bilateral pedal pulses 2+. Abdominal dressing with small serosanguinous drainage. Day 5: Alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Bilateral pedal pulses 2+. Client reports feeling something "popped" at the abdominal incision after coughing. Abdominal dressing with large amount of serosanguinous drainage. Select the 3 findings that require immediate follow-up.