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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should best follow up the assessment finding of an ankle-brachial index (ABI) of 0.40 in the right leg by implementing interventions relevant to arterial narrowing.
An ankle-brachial index is a non-invasive test used to assess peripheral arterial disease (PAD). An ABI value below 0.90 indicates significant arterial narrowing and impaired blood flow to the lower extremities. An ABI of 0.40 suggests severe arterial narrowing, which puts the client at risk for reduced perfusion and potential complications such as tissue ischemia, ulceration, and gangrene.
Implementing interventions relevant to arterial narrowing is crucial in this case. These interventions may include:
- Collaborating with the healthcare provider to develop a treatment plan: This may involve prescribing medications to improve blood flow, such as antiplatelet agents or vasodilators.
- Encouraging lifestyle modifications: This can include smoking cessation, regular exercise, and maintaining a healthy diet low in saturated fats and high in fruits and vegetables.
- Promoting optimal cardiovascular health: This can involve managing other risk factors for arterial narrowing, such as hypertension, diabetes, and high cholesterol levels.
- Educating the client about the signs and symptoms of PAD: This includes teaching them to monitor for changes in skin color, temperature, and sensation in the affected limb, as well as the importance of seeking prompt medical attention if these changes occur.
Let's review the other options:
Assessing the client's use of over-the-counter dietary supplements: While it is important to assess for potential interactions between medications and dietary supplements, this would not be the immediate follow-up action for a severely reduced ABI.
Encouraging the client to increase intake of foods high in vitamin K: While maintaining a balanced diet is important for overall health, increasing vitamin K intake is not specifically indicated for addressing arterial narrowing or improving the ABI.
Adjusting the client's activity level to accommodate decreased coronary output:
Coronary output refers to blood flow to the heart muscle. Arterial narrowing in the leg does not directly affect coronary output. However, it is important to encourage appropriate physical activity for the client based on their overall cardiovascular health and exercise tolerance.
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.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.