The following six questions are part of an unfolding case study.

Review the electronic health record. Which 3 assessment finding(s) require follow-up by the nurse? Select three findings.

Rationale for correct choices

• Atelectasis: Atelectasis is a common post-operative pulmonary complication, especially after orthopedic surgery, due to immobility, shallow breathing, and pain that limits deep inspiration. The client’s elevated respiratory rate (26 breaths/min) and low oxygen saturation (88% on room air) indicate decreased lung expansion.

• Alveolar collapse: Atelectasis occurs when alveoli fail to expand fully or collapse, impairing gas exchange. Post-operative pain and reluctance to ambulate contribute to inadequate lung inflation, promoting alveolar collapse. The client’s recent surgery, immobility, and shallow breathing make alveolar collapse the underlying mechanism of this pulmonary complication.

Rationale for incorrect choices

• Bowel obstruction: Although post-operative clients are at risk for gastrointestinal complications, there is no indication of abdominal distention, absent bowel sounds, vomiting, or constipation. The client’s main issue is respiratory compromise, making bowel obstruction unlikely in this scenario.

• Infection: While surgical site infection is a potential post-operative risk, the client currently shows no fever, wound drainage, or local inflammation. The immediate concern is hypoxia and respiratory compromise, so infection is less likely at this time.

A. Elbows, knees, and shoulders: These areas are at risk for pressure injuries when a client is lying supine or side-lying, but in high-Fowler’s position, they bear less sustained pressure. While still important, they are not the highest-priority sites.

B. Toes, heels, and sacral area: In high-Fowler’s position, pressure is concentrated on the sacrum, heels, and toes due to gravity and immobility. These bony prominences are the most common sites for skin breakdown, making them the priority for assessment. Early detection in these areas prevents pressure injury development.

C. Hands, feet, and abdomen: Hands and abdomen experience minimal sustained pressure in high-Fowler’s position, reducing immediate risk. These sites are less likely to develop pressure injuries compared with major bony prominences.

D. Head, neck, and back: While skin integrity should be monitored, these areas are less prone to pressure injuries in high-Fowler’s position unless there are medical devices or prolonged immobility. They are not the first priority for assessment.