A. Go to nurses’ station to seek assistance
B. Reinsert the organs into the abdominal cavity.
C. Place client in reverse Trendelenburg position
D. Obtain V/S to assess for shock.
Rationale: Nurse should obtain V/S to assess pts current status.
A. Secure the drain to the clients bed sheet.
B. Clam the drain when the client is ambulating
C. Empty & Compress the drain reservoir as needed.
D. Keep the drain higher than the surgical incision.
Rationale: Compressing reservoir produces suction necessary for the drain to function properly.
A. The client states having numbness to the lower extremities bilaterally.
B. Spinal anesthesia is at the T10 level.
C. The client rouses to tactile stimuli.
D. The client reports chest pain.
Rationale: Patient who is postoperative following total knee arthroplasty is at risk for pulmonary embolism. Reports of chest pain or shortness of breathe can indicate pulmonary embolism. The nurse should report these findings to HCP immediately.