0700 Alert and oriented × 4. Post-op day 1 following right total knee arthroplasty. Reports knee pain 5/10, improved with medication. Surgical dressing clean, dry, and intact. Afebrile., HR 94 bpm, BP 110/68 mm Hg, RR 16/min, O2 saturation 95% on room air. Ambulated to chair with assistance.
0700 Client appears anxious and is sitting upright in bed, using accessory muscles to breathe. Respiratory rate 28/min, O₂ saturation 88% on 3 L/min nasal cannula. Bibasilar crackles. +3 pitting edema in both lower extremities. Reports shortness of breath at rest.
0700 Complains of severe right lower quadrant abdominal pain 8/10 with guarding. Temperature 101.3°F (38.5°C), HR 102 bpm, BP 110/68 mm Hg, RR 28/min. Nausea present, vomited x 2 episodes. Client requests ice chips, NPO at this time, awaiting abdominal ultrasound.
0700 Alert and oriented, reports a persistent cough producing thick, yellow sputum. Client reports achy back pain while coughing and moving. Temperature 100.4°F (38°C), HR 98 bpm, RR 24/min, O₂ saturation 93% on 2 L/min. Ambulatory with mild dyspnea.
0700 Client appears anxious and is sitting upright in bed, using accessory muscles to breathe. Respiratory rate 28/min, O₂ saturation 88% on 3 L/min nasal cannula. Bibasilar crackles. +3 pitting edema in both lower extremities. Reports shortness of breath at rest.
0715 Oxygen increased per protocol to 5 L/min, client repositioned to high Fowler’s, continuous cardiac monitoring initiated, and provider notified. Administered IV furosemide as prescribed. Ordered and obtained labs, including basic metabolic panel (BMP, brain natriuretic peptide (BNP), and complete blood count (CBC). Chest X-ray ordered. Inserted a urinary catheter and obtained daily weight. Initiated fluid restriction of 1,500 mL/day. Client voiding 60 mL per 1 hour.
0700 Alert and oriented × 4. Post-op day 1 following right total knee arthroplasty. Reports knee pain 5/10, improved with medication. Surgical dressing clean, dry, and intact. Afebrile., HR 94 bpm, BP 110/68 mm Hg, RR 16/min, O2 saturation 95% on room air. Ambulated to chair with assistance.
0810 Client suddenly becomes restless and anxious, reports sharp chest pain on inspiration, and is short of breath. His respiratory rate is 30/min, heart rate 124 bpm, SpO₂ 84% on room air, and blood pressure 92/64 mmHg.
0820 Following orders received
- Apply oxygen at 4 L/min via nasal cannula
- Start continuous cardiac monitoring
- Obtain STAT CT pulmonary angiography
- Draw STAT arterial blood gases (ABGs)
- Draw STAT coagulation panel
- Administer subcutaneous enoxaparin 1 mg/kg now
- Insert a peripheral IV and start 0.9% NS at 75 mL/hr
- Maintain the head of the bed between 60-90 degrees
- Bedrest with q2h repositioning
After establishing the most likely complications for each client, the nurse prioritizes which interventions to implement immediately to prevent deterioration.
➢ For each client, decide whether the listed interventions are a Priority Action or Not a Priority based on their current assessment and most likely complication.
Each row must have only one response option selected.
- A. Client 1 - encourage early ambulation
- B. Client 1 - restrict fluids to 1 L/day
- C. Client 2 - administer IV furosemide as prescribed
- D. Client 2 - increase oxygen flow per protocol
- E. Client 3 - maintain NPO status
- F. Client 3 - apply heating pad to the abdomen
- G. Client 4 - encourage the use of an incentive spirometer
- H. Client 4 - increase frequency of ambulation as tolerated
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