A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis?

Oxycodone is a narcotic pain medication commonly used after fracture repair but is strongly associated with gastrointestinal side effects, particularly decreased bowel motility. Postoperative clients are already at increased risk for reduced peristalsis due to immobility and anesthesia effects. Recognizing medication-related adverse effects is essential for preventing complications such as constipation, ileus, and discomfort.

Rationale:

• Constipation: Constipation is a well-known and expected adverse effect of opioid medications such as oxycodone. Opioids bind to receptors in the gastrointestinal tract, reducing peristalsis and slowing stool movement through the intestines. This effect is especially significant in postoperative clients who may also have reduced mobility and decreased fluid intake. Without preventive measures, this can progress to fecal impaction and abdominal discomfort.

• Oxycodone prescription: The use of oxycodone directly contributes to decreased gastrointestinal motility and increases the risk of constipation. Even when used appropriately for pain control, opioids commonly disrupt normal bowel function. In postoperative orthopedic clients, this risk is heightened due to immobility and surgical stress.

• Dysrhythmias: There is no indication that the client is at risk for cardiac dysrhythmias based on the provided potassium level or clinical findings. The potassium level of 3.6 mEq/L is within the normal range and does not suggest electrolyte imbalance severe enough to cause arrhythmias. Therefore, this condition is not supported by the patient data.

• Hypoglycemia: The glucose level of 120 mg/dL is within normal range and does not indicate hypoglycemia. Oxycodone does not typically cause low blood sugar. There are no signs of decreased glucose intake or insulin-related issues in this client. Therefore, hypoglycemia is not a relevant risk based on the findings.

• Impaired circulation: Neurovascular checks show intact pulses, warmth, and preserved movement and sensation in both extremities. These findings indicate adequate peripheral perfusion following femur repair. There is no evidence of vascular compromise such as pallor, coolness, or decreased pulses. Therefore, impaired circulation is not currently a risk.

• Hypovolemia: There are no signs of fluid volume deficit such as hypotension, tachycardia, dry mucous membranes, or decreased urine output. The IV fluids are infusing appropriately, and vital signs are not suggestive of volume depletion. Small serosanguinous drainage from a surgical site is expected and not sufficient to cause hypovolemia.

• Neurovascular check: A neurovascular assessment is a monitoring intervention which is performed to detect complications such as impaired circulation, nerve damage, or compartment syndrome after orthopedic surgery. The findings provided (warm toes, intact sensation, 2+ pulses bilaterally) indicate normal perfusion and function. Therefore, the neurovascular check does not place the client at risk for any condition.

• Potassium level: The potassium level of 3.6 mEq/L is within the normal reference range (3.5–5.0 mEq/L), so it does not indicate a current electrolyte imbalance. Dysrhythmias related to potassium disturbances typically occur with significant hypo- or hyperkalemia, neither of which is present. Therefore, this finding does not support development of a complication.

• Glucose level: The glucose level of 120 mg/dL is within the normal or mildly elevated postprandial range and does not indicate hypoglycemia or clinically significant hyperglycemia. There is no evidence of insulin therapy, poor intake, or endocrine dysfunction that would predispose the client to abnormal glucose regulation.

• Femur dressing: The femur dressing showing a small amount of serosanguinous drainage is an expected postoperative finding after orthopedic surgery. Mild drainage indicates normal healing and does not suggest active hemorrhage or infection in this context. There are also no signs of excessive bleeding, swelling, or hemodynamic instability. Therefore, this finding does not contribute to risk for hypovolemia or other complications.

Pressure injuries develop when prolonged pressure over bony prominences leads to impaired tissue perfusion and subsequent ischemia. Risk increases significantly in clients with limited mobility, impaired sensation, poor nutritional status, and decreased ability to reposition independently. Immobility is the most critical contributing factor because it prevents pressure redistribution. Nurses must identify high-risk clients early to implement preventive measures such as repositioning and pressure-relieving devices.

Rationale:
A. A client receiving enteral feeding who can change position independently has a reduced risk of pressure injury because mobility allows regular pressure redistribution. Although nutritional support is important, the ability to reposition independently significantly lowers the risk of tissue ischemia. Therefore, this client is not at highest risk.

B. A client who is alert, responsive, and consumes 25% of meals has some nutritional concerns but maintains cognitive awareness and likely some mobility. While poor intake may contribute to delayed healing, it is not as significant a risk factor as immobility. This client is not at the highest risk for pressure injury.

C. A client who makes frequent slight position changes and walks occasionally has a relatively low risk of pressure injury due to ongoing movement and pressure relief. Even minimal mobility helps maintain adequate tissue perfusion and reduces prolonged pressure over bony areas. Therefore, this client is not the highest risk.

D. A client who is unresponsive to verbal commands and only changes position occasionally is at the highest risk for pressure injury due to severe immobility and inability to independently relieve pressure. Prolonged pressure leads to reduced capillary blood flow, tissue ischemia, and eventual skin breakdown. This combination of impaired cognition and limited mobility places the client at greatest risk.