The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?
Explanation & Rationale
A. Monitor the client's current white blood cell count (WBC): While WBC can indicate infection, this is not an immediate concern at four hours post-op, where serosanguineous drainage is more likely related to surgical bleeding than infection. B. Determine if the wound drainage device is functioning correctly: Excessive drainage could indicate a malfunctioning drain. Ensuring that the wound drainage system is properly working helps reduce fluid accumulation and prevents complications such as hematoma formation. C. Withhold next scheduled dose of low molecular weight heparin: Anticoagulants are used to prevent deep vein thrombosis postoperatively and should not be withheld unless bleeding is active or confirmed excessive, which has not yet been determined. D. Confirm that the continuous passive motion device is intact: While the device supports joint mobility, it is unrelated to assessing or managing wound drainage, which is the priority concern in this situation.