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)?
Clear lung sounds, CPM (continuous passive motion) on.
B. Call bell, side rails, bed in low position, and ambulation aids.
Paresthesia, paralysis, pedal pulses, pallor, and pain.
Blood pressure 138/88, pain scale 7, and respirations 22.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is **b. Oral feeding of a two-year-old child after application of a hip spica cast.**
Choice A rationale:
Participation in staff rounds to record notes regarding client goals is not an appropriate task to delegate to a UAP. This task requires clinical assessment, judgment, and documentation skills that are within the scope of practice of a licensed practical nurse (PN), but not a UAP.
Choice B rationale:
Oral feeding of a two-year-old child after application of a hip spica cast is an appropriate task that the PN can delegate to a UAP. Feeding a stable patient is a routine task that does not require advanced nursing skills or clinical judgment. As long as the child is not at high risk for complications, this task can be safely delegated to a UAP with proper training and supervision.
Choice C rationale:
Evaluation of a client's incisional pain following narcotic administration is not an appropriate task to delegate to a UAP. This task requires clinical assessment, evaluation of medication effects, and critical thinking skills that are within the scope of practice of a PN, but not a UAP.
Choice D rationale:
Assessment of the placement and patency of a nasogastric feeding tube is not an appropriate task to delegate to a UAP. This task requires specialized nursing skills and clinical judgment to ensure the safety and effectiveness of the feeding tube. It is within the scope of practice of a PN, but not a UAP.
Correct Answer is A
Explanation
A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood flow and perfusion, and may be caused by conditions such as shock, dehydration, or hemorrhage.
The other options are not correct because:
- A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood flow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.
- Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
- Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caffeine intake.
 |
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today