A client with diabetes is admitted with a 1 cm size ulcer on the left great toe. The practical nurse (PN) observes that the left foot has a dusky color. While planning the client's care, which intervention should the PN implement first?

Choice A reason: Maintaining the client in a recumbent position is not typically necessary on the first postoperative day following an appendectomy. While it is important to ensure the client is comfortable and to monitor for signs of complications, encouraging mobility as soon as it is safe is generally beneficial. Prolonged bed rest can lead to complications such as deep vein thrombosis (DVT) and respiratory issues. Therefore, this intervention is not the most appropriate for promoting recovery and ensuring the client's well-being.
Choice B reason: Applying moist heat for pain relief is generally not recommended in the immediate postoperative period following an appendectomy. The use of heat can increase blood flow to the surgical site and potentially exacerbate inflammation or swelling. Pain management should be approached with appropriate analgesics as prescribed by the healthcare provider. Additionally, it is crucial to monitor for signs of complications such as infection or hematoma, and moist heat may not be the safest method for addressing postoperative pain in this context.
Choice C reason: Restricting ambulation to the bathroom only may be overly restrictive and can hinder the client's recovery process. Encouraging early and safe ambulation is important to prevent complications like DVT, promote circulation, and support overall recovery. While it is essential to ensure that the client does not overexert themselves, completely restricting movement to only bathroom trips is not conducive to optimal postoperative care. Gradual, supervised ambulation should be encouraged as the client's condition permits.
Choice D reason: Documenting the first bowel movement is a crucial intervention following an appendectomy. It provides important information about the return of gastrointestinal function, which can be affected by both the surgery and anesthesia. Monitoring and recording bowel movements help ensure that the client is not experiencing postoperative ileus, a common complication characterized by a temporary cessation of bowel activity. Early detection of such issues allows for timely intervention and supports the client's overall recovery.

Choice A reason: Using a large cuff to obtain BP readings on either thigh is the appropriate action. With a history of a right radical mastectomy, blood pressure should not be taken on the right arm due to the risk of lymphedema. The left arm is also not suitable due to the recent surgery and cast. Therefore, the thigh is the best alternative site for accurate BP measurement.
Choice B reason: Measuring all vital signs every 2 hours except the BP is not appropriate because BP is a critical vital sign that needs to be monitored regularly, especially in postoperative clients. Omitting BP measurements could miss important changes in the client's condition.
Choice C reason: Obtaining manual BP readings with a cuff on the left arm is not recommended as the client has a recent surgical repair and cast on the left arm. This can cause discomfort and may not provide accurate readings.
Choice D reason: Quickly releasing air from the BP cuff on the right arm is not suitable due to the client's history of right radical mastectomy. This practice could exacerbate the risk of developing lymphedema in the affected arm.