Exhibits

The client is being considered for discharge to home where he will continue to recover. The nurse reassesses the client and evaluates him for discharge readiness.

For each body system, click to specify the assessment finding(s) that would indicate the client is ready for discharge to home.

Each body system may support more than one finding. Each category must have at least one response option selected.

 

Body system	Findings
Cardiovascular	Blood pressure of 120/74 mm Hg Capillary refill of 4 seconds in lower extremities Pedal pulse of 2+ or better
Neurovascular	Pupils equal and nonresponsive to light Absence of numbness or tingling in feet Skin that is pale, cool to touch
Renal Perfusion	Client has urine output of 1,600 mL in 24 hours Creatinine of 1.2 mg/dL (106 mmol/L)

Rationale for Correct Choices:

• Blood pressure of 120/74 mm Hg: This is within the normal range and indicates stable cardiovascular function, which supports discharge readiness following an aortic aneurysm intervention.
• Pedal pulse of 2+ or better: A 2+ pulse signifies adequate peripheral perfusion. It is important for assessing vascular integrity postoperatively, especially for patients with a history of aneurysmal disease.
• Absence of numbness or tingling in feet: Normal neurovascular sensation in the lower extremities suggests intact peripheral nerve and vascular supply, a critical discharge criterion after vascular complications.
• Client has urine output of 1,600 mL in 24 hours: This volume reflects adequate renal perfusion and fluid balance, within the normal range (800-2000 mL/day for adults) both of which are necessary to confirm the kidneys are functioning properly post-recovery.
• Creatinine of 1.2 mg/dL (106 mmol/L): This value is within normal limits (0.6-1.2 mg/dL), indicating that renal function is preserved and not compromised by the previous cardiovascular event or interventions.

Rationale for Incorrect Choices:

• Capillary refill of 4 seconds in lower extremities: A capillary refill time longer than 2–3 seconds suggests impaired perfusion, which would warrant further evaluation before discharge.
• Pupils equal and nonresponsive to light: This indicates a serious neurological deficit, potentially related to brain injury or altered consciousness, and is incompatible with safe discharge.
• Skin that is pale, cool to touch: This suggests possible peripheral hypoperfusion or systemic circulatory compromise and would need to be resolved before considering discharge.