A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to bypass arteries in the right leg. Which assessment should receive the highest priority?
Adequacy of circulation
Patency of airway
Movement of lower leg
Neurovascular status of the left leg
The Correct Answer is A
A. Adequacy of circulation:
This assessment is the highest priority for a client who has undergone a procedure to bypass arteries in the right leg. Monitoring for signs of adequate blood flow, such as color, temperature, capillary refill, and pulses in the operated leg, is critical to identify and address any circulation issues early.
B. Patency of airway:
While maintaining a patent airway is always a priority in postoperative care, it is not the immediate concern in a client who has just undergone a leg bypass procedure. Airway management is essential, but assessing circulation in the operated limb takes precedence.
C. Movement of lower leg:
Assessing movement of the lower leg is important for detecting signs of impaired motor function or complications. However, it is secondary to assessing the adequacy of circulation, which is critical for preventing ischemia and other circulatory issues.
D. Neurovascular status of the left leg:
While monitoring the neurovascular status of the left leg is a valid aspect of the overall assessment, the priority in the immediate postoperative period is to assess the surgical site (right leg) to ensure that blood flow is adequate and that there are no immediate complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.7"]
Explanation
To calculate the amount of hydroxyzine (Vistaril) to administer, use the formula:
D (desired dose) / H (have dose) x Q (quantity) = X (amount to give)
In this case, D = 35 mg, H = 50 mg/mL, and Q = 1 mL. Plug in the values and solve for X:
35 mg / 50 mg/mL x 1 mL = 0.7 mL
Therefore, the amount of hydroxyzine (Vistaril) to administer is 0.7 mL.
Correct Answer is C
Explanation
A. Skin fold:
This may not be the best choice in this situation because the skin fold might not provide an accurate reading, especially if the hands are edematous.
B. Toe:
While the toe is a common site for pulse oximetry, in a patient with bilateral lower leg amputations, it might not be the most practical option. The nurse might face challenges in securing the pulse oximeter probe on the toe, and the accuracy of the reading could be affected.
C. Earlobe:
This is often a suitable alternative site for pulse oximetry when peripheral perfusion is compromised in the extremities. In this case, with bilateral lower leg amputations and edematous hands, applying the pulse oximeter probe to the earlobe is a good choice.
D. Finger:
In a patient with edematous hands, the finger might not be the best choice as the edema could affect the accuracy of the measurement. Additionally, if the patient has lower leg amputations, using the earlobe or another alternative site may be more appropriate.
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