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 D

Explanation

Among the given findings, the most important finding to report to the health care provider in a client with a hypertensive emergency is the new-onset blurry vision and facial asymmetry. These symptoms may indicate that the client is experiencing a hypertensive crisis with potential complications such as hypertensive encephalopathy or stroke.

Blurred vision and facial asymmetry are concerning neurological symptoms that suggest possible damage to the blood vessels or organs in the brain. It is crucial to notify the health care provider immediately so that appropriate interventions can be initiated to address the underlying cause and prevent further complications.

While the other findings may also be associated with elevated blood pressure, the new-onset blurry vision and facial asymmetry indicate possible neurological involvement and require immediate attention. Headache, epistaxis (nosebleed), and decreased urine output may be significant symptoms, but the potential neurological implications make the new-onset blurry vision and facial asymmetry the priority for reporting.

A. Wrap both legs in a warming blanket B. Compare ﬁndings to the preoperative assessment of the pulses C. Document the ﬁndings and recheck in 15 minutes. D. Notify the surgeon and anesthesiologist

Correct Answer is D

Explanation

The nurse should prioritize notifying the surgeon and anesthesiologist as the ﬁrst action. The absent pulses, coolness, and mottled appearance of the leg indicate potential compromised blood ﬂow to the lower extremity, which could be a sign of vascular compromise or acute limb ischemia. These ﬁndings are concerning after the repair of an abdominal aortic aneurysm and require immediate medical attention.

Wrap both legs in a warming blanket: While it is important to maintain the client's body temperature, this action alone may not address the underlying issue of compromised blood ﬂow and potential limb ischemia. Notifying the surgeon and anesthesiologist is the priority to address the immediate concern.

Compare ﬁndings to the preoperative assessment of the pulses: While comparing ﬁndings to the preoperative assessment is important for evaluating the client's condition, it should not delay immediate action. The priority in this situation is to promptly notify the surgeon and anesthesiologist to address the potential vascular compromise.

Document the ﬁndings and recheck in 15 minutes: Documenting the ﬁndings is an important step in the nursing process, but it should not take precedence over immediate intervention. The concerning signs of absent pulses, coolness, and mottled appearance require urgent attention, and delaying notiﬁcation could lead to further complications.

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

Correct Answer is D

Explanation

The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take ﬁrst?

Correct Answer is D

Explanation

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