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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is collecting data on an older adult client who is 8 hours post-operative following a right femoral-popliteal bypass graft. Which of the following findings indicate that the client is physiologically stable and do NOT require immediate reporting to the registered nurse (RN)? Select all that apply.

  1. Capillary refill time of 2 seconds in the toes of the right footAnswer
  2. B
    Heart rate of 114 beats/min and blood pressure of 92/60 mm Hg
  3. C
    Sudden onset of restlessness and confusion regarding current location
  4. Incisional pain rated as 4 on a 0 to 10 pain scale that is reduced by repositioningAnswer
  5. E
    Hemoglobin level of 7.8 g/dL (78 g/L) on the post-operative laboratory report
  6. Oral temperature of 99.1°F (37.3°C) and a respiratory rate of 16 breaths/minAnswer

Answer

The expected, stable findings are a capillary refill time of 2 seconds, incisional pain rated as 4 out of 10, and an oral temperature of 99.1°F with normal respirations.
Stable post-operative adaptation includes manageable pain, adequate peripheral perfusion (capillary refill less than 3 seconds), and a mild inflammatory response (temperature up to 100.4°F or 38.0°C in the first 48 hours). These findings show the client is recovering as expected.

Step-by-Step Solution

1
Analyze the clinical scenario and the specific question being asked.
The client is 8 hours post-operative from a vascular bypass graft. The question asks to identify which findings are expected and stable, meaning they do NOT require immediate escalation.
Understanding the timeline helps differentiate normal post-operative physiological responses from acute complications.
2
Evaluate each option to distinguish normal post-operative data from signs of physiological decompensation.
Normal findings include manageable pain, rapid capillary refill, and a low-grade temperature. Abnormal findings include tachycardia with hypotension, low hemoglobin, and new-onset confusion.
Early recognition of shock, bleeding, or hypoxia is critical to preventing adverse outcomes.
3
Select the options that represent stable, expected outcomes.
The correct selections are the normal capillary refill, the moderate pain, and the mild temperature elevation.
These findings reflect expected post-operative adaptation without indicating acute risk to Airway, Breathing, or Circulation.

Key Concept

Differentiating expected post-operative physiological adaptations from early signs of acute decompensation
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Topics

Physiological Adaptation

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