Question

A practical nurse (PN) is assigned to care for an 82-year-old client who had a total right hip replacement with cement 2 days ago. Which observation(s) should the PN immediately report to the RN? (Select all that apply)

A. The client complains of incisional pain, rating it an 8 on a scale of 0-10
B. The client has had a change in orientation to person but not to time or place.
C. Swelling and redness have developed in the client's lower left leg.
D. The LPN emptied 15 mL of bloody drainage from the Jackson-Pratt drain
E. The client's last set of vital signs was temperature 37.9 C (100.2 F), pulse 87, respirations 12, blood pressure 108/74, and O2 saturation 93%

Answer 1

The observations that the PN should immediately report to the RN are: incisional pain rated 8/10, swelling and redness in the lower left leg, and 15 mL of bloody drainage from the drain.

Step-by-step explanation:

The observation(s) that the practical nurse (PN) should immediately report to the registered nurse (RN) are:

A. The client complains of incisional pain, rating it an 8 on a scale of 0-10

C. Swelling and redness have developed in the client's lower left leg

D. The LPN emptied 15 mL of bloody drainage from the Jackson-Pratt drain

These observations indicate potential complications that require immediate attention. Incisional pain, especially when rated as an 8 on a scale of 0-10, may indicate inadequate pain management or infection. Swelling and redness in the lower left leg may suggest deep vein thrombosis, which is a serious condition that requires intervention. Lastly, the presence of bloody drainage from the drain may indicate bleeding or an infection, which should be addressed promptly.