A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the ﬁrst postoperative day?

Assess pulse of affected extremity every 15 minutes at ﬁrst.

Palpate the affected leg for pain during every assessment

Assess the client for signs and symptoms of compartment syndrome every 2 hours.

Perform Doppler evaluation once daily.

Answer and Explanation

Correct Answer : A,B,C,D

Assess pulse of the affected extremity every 15 minutes at ﬁrst: Frequent assessment of the pulse in the affected extremity is important to monitor for any changes in blood ﬂow. This allows the nurse to identify any potential complications such as graft occlusion or compromised circulation promptly.

Palpate the affected leg for pain during every assessment: Assessing for pain in the affected leg is crucial to identify any signs of ischemia or inadequate perfusion. Increased pain could indicate reduced blood ﬂow or other complications that require immediate attention.

Assess the client for signs and symptoms of compartment syndrome every 2 hours: Compartment syndrome can occur after vascular surgeries, and early recognition is vital. The nurse should assess for signs and symptoms such as pain, numbness, tingling, increased swelling, and tense compartments. Regular assessment every 2 hours can help detect compartment syndrome promptly and prevent further complications.

Perform Doppler evaluation once daily: Doppler evaluation may be ordered by the healthcare provider to assess blood ﬂow and graft patency. However, the frequency of Doppler evaluation may vary depending on the client's condition and the healthcare provider's orders. Once daily assessment is not suﬃcient if there are concerns regarding blood ﬂow or graft viability.

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Correct Answer is C

Explanation

"I will use a heating pad on my feet at night to increase the circulation.": Using a heating pad on the feet at night is not recommended for clients with peripheral artery disease. The application of heat, such as from a heating pad, can dilate blood vessels and potentially worsen the symptoms of peripheral artery disease. This can lead to reduced blood flow to the affected limbs and increase the risk of complications.

The other client statements demonstrate an understanding of peripheral artery disease management:

"I will avoid long periods of sitting down with my legs crossed over." This statement shows awareness of the importance of maintaining good blood flow and avoiding positions that can restrict circulation.

"I will walk to the point of pain, rest, and walk again for at least 30 minutes." This statement indicates an understanding of the concept of intermittent claudication, a common symptom of peripheral artery disease. Walking until pain occurs, resting, and then resuming walking helps improve circulation and increases walking distance over time.

"I will buy some loose clothes that do not bind across my legs or waist." This statement reflects an awareness of the need to wear loose-fitting clothes that do not constrict blood flow to the legs or waist area.

A. The client has a permanent cardiac pacemaker B. The client has a history of atherosclerosis. C. The client took the prescribed heart medications today D. The client has an allergy to shellfish.

Correct Answer is A

Explanation

Having a permanent cardiac pacemaker is a significant factor that needs to be communicated to the health care provider before undergoing an MRI. Magnetic resonance imaging (MRI) uses powerful magnets, radio waves, and a computer to create detailed images of the body. The presence of a cardiac pacemaker can be a contraindication for undergoing an MRI because the strong magnetic field can potentially interfere with the functioning of the pacemaker or cause it to malfunction. It is crucial to assess the compatibility of the pacemaker with the MRI machine and to take appropriate precautions or make necessary arrangements to ensure the safety of the client during the procedure.

While the other pieces of information provided may be relevant to the client's overall health and medical history, they may not have a direct impact on the safety or feasibility of undergoing an MRI.

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A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the ﬁrst postoperative day?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client with chronic peripheral artery disease. What client statement indicates the need for further teaching?

Correct Answer is C

Explanation

The nurse is screening a client prior to an magnetic resonance imaging (MRI). What information is important to report to the health care provider before the MRI?

Correct Answer is A

Explanation

The nurse is conducting client teaching about cholesterol levels. When discussing the client's elevated LDL and lowered HDL levels, the client shows an understanding of the significance of these levels by making what statement?

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The nurse is caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

The nurse is teaching a client with peripheral arterial disease. Which information should the nurse include in the teaching plan?

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