A nurse is planning client education about active range of motion (ROM) exercises. Which instruction should the nurse plan to include in the teaching?

Rationale:

• Blood pressure of 120/82 mmHg: This blood pressure reading is within normal limits for an older adult. While hypotension or significant hypertension may indicate post-operative complications, a reading of 120/82 mmHg does not suggest immediate risk. It is unlikely to represent a complication and is considered stable.

• Body mass index of 26.6: A BMI of 26.6 falls into the overweight category but does not represent an acute post-operative complication. While elevated BMI may contribute to long-term risk factors, it does not indicate an immediate issue following knee replacement surgery.

• Respiration rate of 26 breaths per minute: Tachypnea in a post-operative client may indicate early hypoxia, pulmonary embolism, atelectasis, or pneumonia. After knee replacement surgery, immobility increases the risk of pulmonary complications. Monitoring respiratory status is critical because early detection of pulmonary compromise can prevent severe outcomes.

• Heart rate of 115 beats per minute: Tachycardia can be a compensatory response to hypoxia, pain, anxiety, or early infection. In post-operative clients, elevated heart rate may also indicate blood loss, dehydration, or pulmonary embolism. Continuous monitoring is warranted because persistent tachycardia can precede hemodynamic instability.

• Oxygen saturation of 88% on room air: An oxygen saturation below 90% is clinically significant hypoxemia. After orthopedic surgery, hypoxemia may result from anesthesia effects, atelectasis, or pulmonary embolism. Immediate interventions, such as supplemental oxygen and monitoring for respiratory compromise, are essential.

A. Face the direction of movement: Facing the direction of movement promotes proper body alignment and reduces twisting of the spine during repositioning. This technique improves balance and decreases the risk of musculoskeletal injury. Correct body mechanics are essential when making an occupied bed.

B. Stand with feet close together: Standing with feet close together narrows the base of support and reduces stability. Proper body mechanics require feet to be shoulder-width apart to maintain balance during movement. A stable stance helps prevent falls and back strain.

C. Reach across the bed to grab clean linens: Reaching across the bed causes spinal twisting and overextension of the arms. This movement increases the risk of back injury and shoulder strain. Linens should be positioned within close reach to support ergonomic practice.

D. Maintain the bed in low and locked position: The bed should be locked for safety, but it should be raised to a comfortable working height during care. Keeping the bed low increases the need for bending and strain. Bed height adjustment is part of safe body mechanics.