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The Nurse Is Assessing the Client Who Is Status 4 °\degree

Question 23

Multiple Choice

The nurse is assessing the client who is status 4 hours post total knee arthroplasty. The assessment is as follows: blood pressure (BP) 90/60 mm Hg, pulse (P) 94 beats/min; respirations (R) 16 breaths/min; temperature (T) 98.6 °\degree F, dressing is saturated with frank red blood. The nurse reinforces the dressing and contacts the surgeon. What is the nurse's main concern regarding this client?


A) The client may be hemorrhaging.
B) The client may be hypovolemic.
C) The client is developing an infection.
D) The client is developing a thrombus.

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