While changing the dressing of a client who is immobile, the practical nurse (PN) observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the PN should evaluate which of the client's laboratory values?

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.

The correct answer is choice B. Ineffective airway clearance.

Choice A rationale:

Risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.

Choice B rationale:

Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.

Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.

Choice C rationale:

Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.

Choice D rationale:

Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.