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 A

Explanation

Based on the information provided, the nurse should anticipate that the medical treatment prescribed for a client with an abdominal aortic aneurysm less than 3 cm in size would be regular ultrasound screenings every six (6) months.

Monitoring the size of the abdominal aortic aneurysm through ultrasound is a common approach for managing small aneurysms. Regular ultrasound screenings allow healthcare providers to track the growth rate of the aneurysm and determine if any intervention, such as surgical repair, is necessary as the aneurysm progresses in size.

Let's review the other options and explain why they are not the most appropriate treatments for an abdominal aortic aneurysm less than 3 cm in size:

Intravenous pyelogram yearly: An intravenous pyelogram is an imaging test used to evaluate the urinary system, specifically the kidneys, ureters, and bladder. It is not directly related to the management or monitoring of an abdominal aortic aneurysm.

Assessment of abdominal girth monthly: Assessing the abdominal girth may be a part of the overall assessment of the client's condition, but it is not the primary treatment for managing an abdominal aortic aneurysm. Monitoring the aneurysm size through regular ultrasound screenings is a more specific and accurate approach.

Repair of abdominal aortic aneurysm: Repair of an abdominal aortic aneurysm is typically indicated when the aneurysm reaches a certain size threshold or if it poses a high risk of rupture. For an aneurysm less than 3 cm in size, repair is usually not the initial treatment option. Instead, regular monitoring through ultrasound screenings is recommended to assess the aneurysm's growth rate and determine the appropriate time for intervention.

A. Tremors are noted in the fingers when the patient extends the arms. B. The client has atrial fibrillation on the telemetry monitor C. The client cannot move the left arm and leg when asked to do so. D. The patient reports a headache with pain at level 7 of 10 (0 to 10 scale).

Correct Answer is C

Explanation

The inability to move the left arm and leg suggests a neurological deficit, which is a significant finding that requires immediate attention. It could indicate a potential stroke or another neurological emergency that requires prompt evaluation and intervention. The health care provider needs to be notified immediately so that appropriate diagnostic tests and interventions can be initiated.

Tremors in the fingers when extending the arms can be a sign of tremor disorders or medication side effects but may not warrant immediate intervention.

Atrial fibrillation is a cardiac arrhythmia that requires monitoring and management but may not be directly related to the acute neurological issue.

The headache reported by the patient, although significant, is subjective and may be related to the hypertensive emergency or other factors but does not require immediate intervention compared to the potential neurological deficit.

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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 reviewing the medical electronic record of a client with abdominal aortic aneurysm less than 3 cm in size. Which medical treatment should the nurse anticipate to be prescribed for the client?

Correct Answer is A

Explanation

The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

Correct Answer is C

Explanation

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four clients. Which nursing action can be delegated to the UAP?

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?

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

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 discussing discharge teaching with the client who is three (3) days post-operative abdominal aortic aneurysm repair. Which information should the nurse include in the teaching?

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

The nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. Which intervention is the most appropriate for this diagnosis?

The nurse is caring for a client with a pacemaker/ICD on a continuous cardiac monitor. Which trace should require immediate follow up by the nurse? Select all that apply