An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy once a day. Which problem should the nurse identify as a priority for this patient?

Hip spica casts are typically used to immobilize the hip joint and are often used in the management of hip dysplasia or after surgery. These casts can cause restricted mobility and limit blood flow to the legs and feet, which can lead to complications such as swelling, decreased circulation, or pressure sores.

Checking capillary refill in the toes is a critical nursing intervention to assess for the presence of adequate circulation and blood flow to the affected limb. If capillary refill is slow or absent, it may indicate compromised circulation and require immediate intervention to prevent further complications.

Palpating a brachial pulse, assessing bilateral radial pulses, or auscultating the heart rate apically are not the priority nursing actions for an infant with a hip spica cast. While monitoring vital signs and circulation are important components of nursing care, the priority at this stage is to assess and manage the immediate postoperative needs of the patient, including monitoring for potential complications related to the hip spica cast.

Pneumonia is an infection that causes inflammation in the lungs. Auscultation refers to listening to the sounds produced by the lungs using a stethoscope. Ronchi and fine crackles are abnormal lung sounds that can be heard during auscultation in individuals with pneumonia.

These sounds are associated with the presence of fluid or mucus in the lungs, which is characteristic of pneumonia.

While other symptoms such as a sore throat, tympany noted on chest percussion, and a slightly elevated temperature (37.8 degrees Celsius) can be present in various respiratory conditions, the auscultation findings of ronchi or fine crackles specifically suggest an underlying lung infection like pneumonia.