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An older male client is returning to the surgical unit after a total right knee replacement. Which assessment findings are most important for the practical nurse (PN) to document in this client's electronic medical record (EMR)?

A.

Clear lung sounds, CPM (continuous passive motion) on.

B.

B. Call bell, side rails, bed in low position, and ambulation aids.

C.

Paresthesia, paralysis, pedal pulses, pallor, and pain.

D.

Blood pressure 138/88, pain scale 7, and respirations 22.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C - Paresthesia, paralysis, pedal pulses, pallor, and pain.

Choice A rationale:

Clear lung sounds, CPM (continuous passive motion) on. While assessing lung sounds and the

use of CPM after knee replacement is essential, it may not be the most critical information to document in the client's electronic medical record (EMR) compared to other potential complications.

Choice B rationale:

Call bell, side rails, bed in low position, and ambulation aids. These are important safety measures and assistive devices for the client's post-operative recovery. While documenting these measures is important, they are not the most crucial findings to be documented in the EMR.

Choice C rationale:

Paresthesia, paralysis, pedal pulses, pallor, and pain. After a total knee replacement, it is crucial to assess the neurovascular status of the affected leg to identify any potential complications like nerve damage, circulatory impairment, or blood clot formation.

Documenting these assessments in the EMR helps monitor the client's progress and identify any changes that may require immediate intervention.

Choice D rationale:

Blood pressure 138/88, pain scale 7, and respirations 22. While monitoring vital signs and pain levels is important, these parameters are not the top priority in this situation.

Neurovascular assessments are more critical for the early detection of complications.


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Related Questions

Correct Answer is ["A","C","D"]

Explanation

The correct answer is choice A, C, and D. Choice A rationale: Boiled brown rice is a good option for a client with renal disease needing to limit salt intake. It is low in sodium and does not contribute to fluid retention. Choice B rationale: Canned tomato soup is typically high in sodium, which can lead to fluid retention and increased blood pressure, making it an unsuitable choice for someone with renal disease who needs to limit salt intake. Choice C rationale: Fresh orange slices are low in sodium and high in vitamin C. They do not contribute to fluid retention and are suitable for a client with renal disease on a low-salt diet. Choice D rationale: Grilled chicken, especially if not seasoned with salt, is a low-sodium protein source that fits within the dietary restrictions for a client with renal disease. Choice E rationale: Vegetables are generally a good choice, but topping them with cheddar cheese increases the sodium content significantly, making it an inappropriate choice for someone on a low-salt diet, as cheese is often high in sodium.

Correct Answer is B

Explanation

The correct answer is choice B, Serum creatinine. Choice A rationale:

The white blood cell count (WBC) is an important parameter for assessing the body's immune response to infections. While it can provide valuable information about the presence of an infection, it is not directly related to nephrotoxicity. Therefore, it is not the most important laboratory value to review before administering an antibiotic that can cause nephrotoxicity.

Choice B rationale:

Serum creatinine is a crucial laboratory value to assess kidney function. It is a waste product that is filtered by the kidneys, and its level in the blood is a reliable indicator of kidney function. If the serum creatinine level is elevated, it suggests impaired kidney function, which can be a warning sign of nephrotoxicity. Reviewing the serum creatinine level before administering nephrotoxic antibiotics is essential to ensure that the client's kidneys are functioning adequately and to avoid potential harm.

Choice C rationale:

Hemoglobin and hematocrit are indicators of the client's red blood cell count and blood's oxygen-carrying capacity. While these values can provide information about the client's overall health status, they are not directly related to nephrotoxicity. Therefore, they are not the most important laboratory values to review in this particular scenario.

Choice D rationale:

Serum calcium levels are essential for assessing bone health, nerve function, and muscle contractions. However, they are not directly related to nephrotoxicity, and reviewing serum calcium levels alone would not provide sufficient information about kidney function. Hence, it is not the most critical value to review before administering nephrotoxic antibiotics

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