A nurse is caring for a client who is using a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?

Choice A reason: Serosanguineous drainage, which is a mixture of blood and a clear yellow liquid known as serum, is generally expected after surgery. While the amount of 150 mL may seem significant, it is not uncommon in the first hour postoperatively, especially after abdominal surgery. The nurse should continue to monitor the drainage and report if the volume increases significantly or if the drainage becomes bright red, indicating active bleeding.

Choice B reason: Greenish-yellow drainage is typically bile, which can be present in NG tube drainage after abdominal surgery. This type of drainage is not unusual and does not necessarily need to be reported unless accompanied by other concerning symptoms or changes in the patient's condition.

Choice C reason: 100 mL of red drainage is concerning and should be reported to the provider immediately. Red drainage suggests active bleeding, and in the context of the first postoperative hour, it could indicate a complication such as hemorrhage. Prompt assessment and intervention are required to address this potential emergency situation.

Choice D reason: Brown drainage may be old blood or could be related to the contents of the gastrointestinal tract. While 200 mL is a larger volume, brown drainage is not typically as concerning as bright red drainage. However, the nurse should monitor for changes in the color and consistency of the drainage, as well as the patient's vital signs and overall status.

Choice A reason: The statement that a DNR prescription means the client will only receive pain medication is incorrect. A DNR (Do Not Resuscitate) order does not affect the provision of treatments other than those required to resuscitate the patient if their heart stops or they stop breathing. Patients with a DNR can still receive all other medical treatments and interventions aimed at managing symptoms and improving quality of life, including pain management.

Choice B reason: A DNR prescription does not limit the current treatment regimen in terms of ongoing treatments for the patient's condition. The DNR order specifically refers to not performing CPR (cardiopulmonary resuscitation) if the patient's breathing or heart stops. All other aspects of the patient's care plan, including aggressive treatments, can continue if they align with the patient's wishes and medical advice.

Choice C reason: This is the correct statement. A DNR prescription allows the patient to continue with their current treatment regimen. It is a directive that applies only in the event of cardiac or respiratory arrest, indicating that CPR should not be performed. However, it does not preclude the patient from receiving other medical treatments or interventions.

Choice D reason: A DNR prescription does not inherently limit the ability to receive invasive procedures. The decision to pursue or avoid invasive procedures would be based on the patient's overall treatment goals, prognosis, and personal preferences, not solely on the presence of a DNR order.