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)?
Explanation & Rationale
A. Call bell, side rails, bed in low position, and ambulation aids: These are safety measures important to prevent falls, but they do not reflect the client’s immediate postoperative neurovascular status or potential complications. B. Clear lung sounds, CPM (continuous passive motion) on: Monitoring lung sounds and CPM use is part of routine postoperative care. While important, these findings are not as urgent as neurovascular assessments in detecting limb compromise. C. Paresthesia, paralysis, pedal pulses, pallor, and pain: Documenting changes in sensation, motor function, circulation, or severe pain helps detect complications such as compartment syndrome, vascular compromise, or nerve injury, which require immediate intervention. D. Blood pressure 138/88, pain scale 7, and respirations 22: Vital signs and pain rating provide useful information on overall status, but they do not specifically address the neurovascular integrity of the operative limb, which is the highest-priority assessment after knee replacement.