A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?
Bruising around the incisional site
Pallor in the affected extremity
Urine output 150 mL over 4 hr
Temperature of 37.9° C (100.2° F)
The Correct Answer is B
B. Pallor suggests potential compromised arterial blood flow or perfusion issues, which require immediate assessment and intervention to ensure the viability of the revascularized artery and the extremity.
A Bruising can be a common finding after surgery, especially involving vascular procedures. It is typically due to minor bleeding into the tissues around the surgical site.
C. Postoperative oliguria (low urine output) can indicate inadequate renal perfusion, which may result from hypovolemia or impaired cardiac output. 150ml in 4 hours does not immediately indicate a need for urgent intervention
D. A mild increase in temperature is common in the immediate postoperative period and can be due to the body's normal response to surgical stress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Laryngeal edema, or swelling of the larynx (voice box), is a hallmark feature of severe anaphylaxis. It can lead to airway obstruction and respiratory distress, which are critical components of an anaphylactic reaction.
A Arrhythmias (abnormal heart rhythms) can occur as a result of various causes, including medications, but they are not specific to anaphylaxis. They may or may not be present during an anaphylactic reaction.
C. Hypertension (high blood pressure) is not a typical feature of anaphylaxis. Instead, hypotension (low blood pressure) is more commonly associated with anaphylactic shock, which is a severe form of anaphylaxis.
D. Fever is not typically associated with anaphylaxis. Anaphylactic reactions typically involve rapid onset of symptoms such as flushing, hives, swelling, respiratory distress, and potentially cardiovascular collapse, but not fever.
Correct Answer is A
Explanation
A Hyperthermia is a hallmark sign of thyroid storm due to the body's increased metabolic rate and inability to dissipate heat efficiently. High fever is a critical sign that should prompt immediate medical evaluation and treatment.
B. While fatigue and lethargy can occur in hyperthyroidism, they are not prominent features of thyroid storm. Individuals with thyroid storm typically exhibit agitation, restlessness, or even delirium due to the effects of excessive thyroid hormone on the central nervous system.
C. Bradycardia is not a feature of thyroid storm. Instead, individuals typically experience severe tachycardia, which can lead to palpitations, chest pain, and cardiovascular complications.
D. Thyroid storm is more commonly associated with hypertension rather than hypotension. Increased cardiac output and vascular resistance contribute to elevated blood pressure during thyroid storm.
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