A nurse is monitoring a client for complications following surgery. Exhibits Complete the following sentence by using the lists of options. The client is at greatest risk for developing dropdownas evidenced bydropdown.
Explanation & Rationale
Rationale for correct choices: Pneumonia: The client has an elevated temperature, productive cough with thick white mucus, and mild crackles in the upper lobes. These findings, combined with recent immobility after surgery, indicate pulmonary infection risk. Respiratory findings: Crackles, cough, and sputum production directly support pneumonia as the complication most consistent with the client’s presentation. Rationale for incorrect choices: Deep vein thrombosis: Although the client has nonpitting edema in the right leg, distal circulation is intact (pedal pulse 2+, capillary refill <2 seconds, foot warm). No calf pain, erythema, or unilateral swelling progression is reported. Urinary tract infection: The client voided a large amount of amber urine without dysuria, urgency, or suprapubic discomfort. No urinary abnormalities have been noted to suggest UTI. Nonpitting edema: This finding is expected locally after knee arthroplasty and does not indicate systemic infection. Elevated temperature: Fever alone is nonspecific and could be related to multiple postoperative risks; the respiratory findings provide more precise evidence for pneumonia.