Difficulty: Medium
Average Score: 78%
Simulated
Passage / Scenario
Vital SignsNurses' Notes
Laboratory Results
Provider's Prescriptions
Temperature: 38.1┬░C (100.6┬░F)
Heart rate: 122/min
Respiratory rate: 20/min
Blood pressure: 109/58 mmHg
SpOÔéé: 96% on room air
A nurse on a rehabilitative unit is caring for a 65-year-old female client who is postoperative following knee arthroplasty. The nurse is evaluating the client. Select the 2 findings that require immediate follow-up.
Correct answer
B,C
Rationale
The correct answers are B and C. For a postoperative client following knee arthroplasty, immediate follow-up is needed for urinalysis (B) to monitor for signs of infection or other urinary issues. Report of sensation upon urination (C) is crucial as it can indicate urinary retention or infection. Monitoring oral fluid intake (A) is important but not as urgent as B and C in this context. Checking the color of urine (D) is also important but does not require immediate follow-up compared to B and C.