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Difficulty: MediumReduction of Risk Potential

A practical nurse (PN) is assigned to care for a client who had a total knee arthroplasty 2424 hours ago and is receiving subcutaneous enoxaparin. While reviewing morning data and preparing for care, which of the following findings should the PN prioritize and report immediately to the registered nurse (RN)?

  1. A
    A missing client identification band that requires verification using the medical record and a second identifier before medication administration.
  2. B
    A resting blood pressure of 114/72 mm Hg114/72\text{ mm Hg} and a heart rate of 8484 beats per minute.
  3. A morning hemoglobin level of 7.4 g/dL7.4\text{ g/dL} (74 g/L74\text{ g/L}), a significant decrease from the previous day's result of 12.8 g/dL12.8\text{ g/dL} (128 g/L128\text{ g/L}).Answer
  4. D
    A client request to modify their customized discharge mobility care plan to better suit their home environment.

Answer

The significant decrease in the hemoglobin level must be reported immediately.
The correct answer identifies a severe drop in hemoglobin, which is a critical laboratory finding indicating potential internal hemorrhage. Because the client had major surgery and is on an anticoagulant, the practical nurse must immediately escalate this finding to the registered nurse so that the anticoagulant can be held and treatments (such as a blood transfusion) can be initiated.

Step-by-Step Solution

1
Analyze the client's clinical scenario and associated risks.
The client recently underwent major orthopedic surgery and is receiving an anticoagulant (enoxaparin), placing them at a high risk for postoperative bleeding.
Identifying the client's primary physiological risks directs the nurse to look for specific complications.
2
Evaluate each assessment finding against expected baseline data and LPN scope of practice.
The vital signs are normal, the ID band issue is a routine safety hurdle, and the care plan modification is a non-urgent RN task. The hemoglobin drop is the only critical, life-threatening finding.
Prioritization requires distinguishing between stable/expected findings, procedural tasks, and acute physiological deterioration.

Key Concept

Prioritizing Critical Laboratory Values in Postoperative Care
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Topics

Reduction of Risk Potential

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