A nurse is assisting with the care of a client.

Select the 3 findings that require immediate follow up

A. Complete activities with one client before moving to another client: Focusing on only one client at a time can reduce efficiency, especially when tasks can be clustered. Effective time management often involves grouping similar tasks across clients to minimize unnecessary movement and interruptions.

B. Plan a time at the end of the shift to document nursing interventions: Delaying documentation until the end of the shift increases the risk of omissions and inaccuracies. Timely, ongoing documentation throughout the shift supports accuracy and safe continuity of care.

C. Make a priority to-do list at the beginning of the shift: Creating a prioritized task list helps the nurse organize care based on urgency and client needs. This approach improves efficiency and ensures that high-priority interventions are addressed first.

D. Delegation of vital signs to the assistive personnel on the team: Delegating routine tasks such as vital signs allows the nurse to focus on assessments and interventions requiring professional judgment. Appropriate delegation is a key strategy for effective time management.

E. Keep track of how long it takes to complete certain tasks: Monitoring how long tasks take helps the nurse plan more realistically and adjust workflow. This awareness supports better scheduling and improved efficiency over time.

A. Check the client's pedal pulses every hour: Frequent assessment of distal circulation is crucial after a total knee arthroplasty to detect signs of compromised blood flow, such as thromboembolism or compartment syndrome. Monitoring pulses, skin color, and temperature helps identify early complications and prevent tissue damage.

B. Maintain the head of the client's bed in high-Fowler's position: High-Fowler’s position is not recommended post-knee arthroplasty as it can increase strain on the surgical site and reduce venous return from the lower extremities. Keeping the leg elevated and the client in a semi-Fowler’s or supine position is safer.

C. Remove the client's dressing when it becomes saturated: Dressings should only be removed or changed according to the provider’s protocol, typically by sterile technique. Premature removal can increase the risk of infection and disrupt the healing surgical site.

D. Place an abductor wedge under the client's right knee: Abductor wedges are primarily used after hip replacement to maintain hip alignment, not knee arthroplasty. Placing one under the knee could cause discomfort or improper positioning. Proper knee alignment involves elevation and extension support.