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 A
Explanation
A. Validate the finding:
Validating the finding involves rechecking the patient's temperature using a different thermometer or method to confirm the accuracy of the initial measurement. This step is crucial to rule out any potential errors or issues with the measurement.
B. Document the finding:
Once the finding has been validated and confirmed, the nurse should document the elevated temperature accurately in the patient's medical record. Documentation is essential for communication among the healthcare team and for tracking changes in the patient's condition over time.
C. Inform the surgeon:
If the elevated temperature is confirmed and the patient is scheduled for surgery, it is important to inform the surgeon promptly. The surgeon needs to be aware of any changes in the patient's health status that may impact the decision to proceed with the scheduled surgery.
D. Inform the charge nurse:
Informing the charge nurse may be appropriate, especially if there are specific protocols or procedures in place within the healthcare facility for addressing unexpected changes in a patient's condition. The charge nurse can provide guidance and coordinate appropriate actions.
Correct Answer is D
Explanation
A. Develop a plan of care for the client:
Developing a plan of care is essential, but it should be informed by the client's current condition, diagnosis, and code status. Documenting the code status is a foundational step.
B. Provide a schedule of visiting hours to the client’s family:
While facilitating family involvement is important, it is not the top priority during the initial admission assessment. Ensuring the client's safety and understanding their code status takes precedence.
C. Teach the client about his diagnosis:
Patient education is important, but in a critical situation, the priority is to assess and document key information, including the code status. Education can follow once the immediate priorities are addressed.
D. Document the client’s code status
When conducting the initial admission assessment for a critical client, the priority action is to document the client's code status. Code status refers to the set of directives given by the client or their legal representative regarding the use of cardiopulmonary resuscitation (CPR) and other life-sustaining measures in the event of a cardiac or respiratory arrest.
Understanding and documenting the client's code status is crucial for informing the healthcare team about the client's preferences for resuscitation efforts. This information guides the team in providing care that aligns with the client's wishes and values.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today