Difficulty: Medium
Average Score: 64%
Simulated
The nurse is caring for a client six hours postoperative following a below-knee amputation (BKA). Which of the following assessment findings requires follow-up?
Correct answer
A
Rationale
Restlessness can be a sign of pain, anxiety, or hypoxia, all of which require follow-up in a postoperative client. The blood pressure and pulse rate are within normal limits, and hypoactive bowel sounds are expected shortly after surgery due to anesthesia and reduced gastrointestinal motility.