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Difficulty: MediumReduction of Risk Potential

A practical nurse is assessing a client who is 24 hours24\text{ hours} post-operative following a right total knee arthroplasty. Which of the following findings should the practical nurse identify as potential complications requiring immediate notification of the registered nurse? Select all that apply.

  1. The client's right calf is swollen, red, and warm to the touch.Answer
  2. The client reports a sudden onset of shortness of breath and an oxygen saturation of 88%88\% on room air.Answer
  3. The client's most recent serum hemoglobin level is 7.1 g/dL7.1\text{ g/dL}.Answer
  4. D
    The client's morning serum potassium level is reported as 4.1 mEq/L4.1\text{ mEq/L}.
  5. E
    The client has a heart rate of 84 beats per minute84\text{ beats per minute} and a blood pressure of 118/76 mmHg118/76\text{ mmHg}.
  6. F
    The client reports an incisional pain level of 44 on a 00 to 1010 scale during physical therapy exercises.

Answer

The findings that require immediate notification of the registered nurse are the swollen, red, and warm right calf; the sudden onset of shortness of breath with an oxygen saturation of 88%; and the critically low serum hemoglobin level of 7.1 g/dL.
The correct choices represent severe, life-threatening post-operative complications. A swollen, red, and warm calf suggests a deep vein thrombosis (DVT). Sudden shortness of breath and hypoxia suggest a pulmonary embolism (PE). A hemoglobin level of 7.1 g/dL is a critical laboratory value indicating severe anemia or potential hemorrhage. All of these require immediate escalation to the registered nurse for prompt medical intervention.

Step-by-Step Solution

1
Evaluate each assessment finding to determine if it is an expected post-operative finding or a potential complication.
The calf symptoms, sudden shortness of breath, and low hemoglobin are identified as abnormal and potentially life-threatening.
Clients recovering from total joint arthroplasties carry a high risk for venous thromboembolism (DVT and PE) and significant blood loss.
2
Determine the appropriate scope of practice for the practical nurse regarding the identified abnormal findings.
The practical nurse must immediately escalate these critical findings to the registered nurse for further assessment and provider notification.
The registered nurse is responsible for the overall nursing care plan, complex assessments, and coordinating emergency medical interventions.

Key Concept

Early Recognition of Post-Operative Complications
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Topics

Reduction of Risk Potential

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