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

The most important finding to report to the health care provider would be the serum potassium level of 3.0 mEq. This is an extremely low potassium level (normal range is typically 3.5-5.0 mEq/L), which can indicate a potentially life-threatening condition called hypokalemia. Furosemide (Lasix) is a diuretic medication that can cause potassium loss in the urine, and a low potassium level can lead to serious cardiac and muscle abnormalities. It is crucial to report this finding promptly to the health care provider for appropriate intervention and monitoring.

Blood glucose level of 175 mg/dL: While an elevated blood glucose level can be a concern, especially for individuals with diabetes, it is not the most critical finding in this situation. The client's primary concern is hypertension, and the administration of IV furosemide is aimed at managing blood pressure. The elevated blood glucose level should still be addressed and monitored, but it is not as urgent as the low potassium level.

Orthostatic systolic BP decrease of 12 mm Hg: Orthostatic hypotension refers to a significant decrease in blood pressure upon standing up. While it is important to assess and manage orthostatic changes, a decrease of 12 mm Hg in systolic blood pressure alone may not be considered clinically significant. It could be a normal response for some individuals. However, if the client experiences symptoms such as dizziness or lightheadedness upon standing, further evaluation may be necessary. Nonetheless, it is not as urgent as the low potassium level.

Current blood pressure reading of 166/94 mm Hg: While this blood pressure reading indicates hypertension, it is not the most critical finding to report in this situation. The nurse is preparing to administer furosemide (Lasix), which is a medication commonly used to treat hypertension. It is expected that the blood pressure will be high before administering the medication. The goal is to monitor the blood pressure after the administration to assess the effectiveness of the medication.

A. Soak feet in warm water for an hour each day B. Set heating pads on a low temperature. C. Use callus remover for corns or calluses D. Wear ﬁtted closed toe shoes daily.

Correct Answer is D

Explanation

Wear ﬁtted closed toe shoes daily: It is important for clients with peripheral arterial disease to wear properly ﬁtted closed toe shoes. This helps protect the feet from injury and provides support. Closed toe shoes also help maintain warmth and prevent heat loss, which is especially important for individuals with impaired circulation.

Let's review the other options and explain why they may not be appropriate:

Soak feet in warm water for an hour each day: Soaking the feet in warm water for a prolonged period can actually worsen symptoms in individuals with peripheral arterial disease. It can cause further dilation of blood vessels, leading to increased blood pooling and potential tissue damage. Therefore, soaking the feet for extended periods of time is not recommended.

Set heating pads on a low temperature: Using heating pads, especially at high temperatures, can be harmful to individuals with peripheral arterial disease. It can increase the risk of burns or thermal injury due to reduced sensation in the affected areas. Heating pads should be used with caution and on a low temperature setting, if necessary.

Use callus remover for corns or calluses: Individuals with peripheral arterial disease have reduced blood ﬂow to the lower extremities, which can impair wound healing. It is important to avoid self-treatment of corns or calluses, as it can increase the risk of skin breakdown and infection. Clients should be advised to consult a healthcare professional, such as a podiatrist, for appropriate management of corns and calluses.

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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

The nurse is preparing to administer IV furosemide (Lasix) to a client with hypertension. What is the most important finding to report to the health care provider?

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a client with hypertension who has a new prescription for enalapril (Vasotec). Which statement of the nurse to the patient would require the charge nurse's intervention?

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The nurse is caring for a client with hypertension who is on alpha blockers. The nurse is concerned about postural hypotension. Which information should the nurse include in the teaching plan?

The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

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The nurse is assessing a client with a hypertensive emergency. Which ﬁnding is most important to report to the health care provider?

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

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