The nurse would immediately report to the surgeon which findings in a client who had a total knee replacement within the last 24 hours?
1. Capillary refill time of 5 seconds in the toes of the surgical leg
2. Slight pallor and skin coolness bilaterally
3. Diminished sensations in both legs and feet
4. Motor strength of 4 in the unaffected leg
Capillary refill time of 5 seconds in the toes of the surgical leg
Rationale: Capillary refill times of less than 3 seconds are considered normal; it is prolonged in this client, which might indicate compromised arterial flow in the surgical leg, and notification is necessary. Pallor and cool skin temperature can reflect arterial flow decreases, but in this client, it is bilateral in nature; it needs further investigation but it is not urgent and probably not related to the surgery itself and does not require immediate notification. Diminished sensations in both legs are a reflection of prolonged neurovascular changes and should be compared to the presurgical status; it is probably not related to the surgery itself and immediate notification is not required. Motor strength in the unaffected leg of 4 does not require immediate notification to the health care provider, and it is probably not related to the surgery.
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