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 ["20"]
Explanation
To administer the ordered dose of furosemide (Lasix) 20mg, you need to calculate the amount of mL required from the available solution. The available solution has a concentration of 2 mg/2 mL, which means that for every 2 mL of solution, there are 2 mg of furosemide. To find the amount of mL needed to deliver 20 mg of furosemide, you can use the following formula:
mL = (ordered dose / available dose) x available volume
Plugging in the values, we get:
mL = (20 mg / 2 mg) x 2 mL
mL = 10 x 2 mL
mL = 20 mL
Therefore, you need to administer 20 mL of the available solution to give the patient 20 mg of furosemide.
Correct Answer is ["B","D","E"]
Explanation
A. Wait 30 min and return to measure the oral temperature:
Waiting 30 minutes may not be necessary. It's more practical to take immediate steps to address potential factors affecting the reading.
B. Provide the client a sip of warm water, wait 5 min, and measure the temperature:
This can be a reasonable and practical approach to stimulate blood flow in the oral cavity and achieve a more accurate oral temperature reading.
C. Document that the nurse was unable to measure the client’s temperature:
Before documenting an inability to measure the temperature, the nurse should attempt appropriate interventions, such as warming the oral cavity or using an alternate route
D. Determine if the client has eaten or drank within the last 15 minutes:
Eating or drinking something cold shortly before taking an oral temperature can result in a lower reading. Checking for recent intake is important to ensure the accuracy of the measurement.
E. Use an alternate route (i.e., axillary, rectal) to take the client’s temperature:
If the oral temperature reading remains difficult to obtain or is not reliable, using an alternate route may be necessary. However, this depends on the client's condition, the reason for the temperature measurement, and the healthcare facility's protocols.
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