The nurse is performing a musculoskeletal assessment with a client. Which action(s) should the nurse implement when performing passive range of motion (PROM) exercises with a client? Select all that apply.

Rationale for Correct Choices:

• The client reports he was able to sleep through the night: Adequate rest indicates improved comfort and effective pain management postoperatively.
• The left arm is warm to touch: Warmth confirms adequate circulation and tissue perfusion following surgery.
• The client's left shoulder and collarbone are symmetric: Symmetry suggests proper surgical alignment and absence of acute displacement or swelling.

Rationale for Incorrect Choices:

• Continued numbness in the left arm, tingling, and inability to move fingers: These findings raise concern for possible neurovascular compromise or prolonged effects of the nerve block.
• Mild nausea and lack of desire to eat breakfast: This can be a transient side effect of anesthesia or analgesics but requires monitoring for persistence.
• A 3 cm × 5 cm area of blood noted on the bandage: Postoperative dressings should have minimal drainage, so this amount of blood warrants assessment for active bleeding or hematoma formation.

A. Left arm that is cool to touch: A cool extremity can indicate impaired circulation, which is a priority concern after trauma. It may suggest compromised perfusion or neurovascular compromise, requiring immediate further investigation.

B. Decreased range of motion: The inability to move the left arm signals possible fracture, dislocation, or neurovascular impairment. Limited mobility after trauma should always be investigated to determine the extent of musculoskeletal injury.

C. Swelling at the site of injury: Swelling is expected following trauma and does not necessarily indicate a complication. While it should be monitored, it is not as urgent to investigate further compared with circulation or alignment changes.

D. Intense pain reported by client: Severe, constant pain out of proportion to the injury raises concern for complications such as compartment syndrome, fracture, or vascular compromise. This finding requires prompt further assessment and intervention.

E. Oxygen saturation 95% on room air: Although slightly lower than ideal, this level is still acceptable in an older adult and not immediately alarming. It does not require urgent further investigation compared to other more critical findings.

F. Blood pressure of 136/90 mm Hg: This blood pressure indicates mild hypertension but is not an acute concern in the setting of trauma. It does not require urgent investigation at this point.

G. Nausea and fatigue reported by client: These symptoms may suggest a head injury, concussion, or internal response to trauma. Given the reported head impact, these findings warrant further neurological evaluation.

H. Bone misalignment: Visible misalignment strongly suggests fracture or dislocation. This finding must be investigated further to confirm the diagnosis and prevent neurovascular complications.