The nurse would immediately report to the surgeon which finding in a patient who had a total knee replacement within the last 24 hours?

Question

1. Diminished sensations in both legs and feet
2. Motor strength of 4 in the unaffected leg
3. Capillary refill time of 5 seconds in the toes of the surgical leg
4. Slight pallor and skin coolness bilaterally

Answer 1

3
Rationale 1: Diminished sensation in both legs is 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.
Rationale 2: Motor strength of 4 in the unaffected leg does not require immediate notification of the health care provider; it is probably not related to the surgery.
Rationale 3: A capillary refill time of less than 3 seconds is considered normal. It is prolonged in this patient, which might indicate compromised arterial flow in the surgical leg, and notification is necessary.
Rationale 4: Pallor and cool skin temperature can reflect arterial flow decreases, but in this patient it is bilateral. This finding needs further investigation, but it is not urgent and probably not related to the surgery itself.