Exhibits The nurse is performing the morning assessment with the client. Highlight the assessment findings that require follow-up by the nurse. The client is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is client-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL an hour. General: Alert, oriented to person, place, and time. Eyes: Pupils round, reactive to light and accommodation (PERRLA). Lungs: Lungs clear all lobes. Heart: Tolometry monitor displaying sinus rhythm (SR). Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow. Right leg: Right leg incision is open to air, skin to the area is cool to touch, and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 mL red drainage present right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area. Left leg: 2+ pedal pulse, loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toenails noted, and capillary refill is greater than 4 seconds.