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 C
Explanation
C. This statement highlights difficulty with a specific ADL (grooming) that OT can assess and intervene to improve independence and quality of life.
A Difficulty swallowing, preference for a wheelchair over a walker, and problems with bladder control may also require medical attention, but they are not directly related to the occupational therapy's primary focus on improving the patient's ability to perform daily activities
B. This statement suggests mobility issues and possibly difficulty with walking due to muscle weakness. While mobility aids such as wheelchairs and walkers are typically addressed by physical therapists, OT can also be involved in evaluating the client's preferences, abilities, and functional mobility needs.
D. While OT primarily focuses on ADLs and functional tasks, bladder control problems typically require evaluation and management by a urologist or specialist in urology.
Correct Answer is C
Explanation
C. Muscle twitching post-thyroidectomy can indicate hypocalcemia, a common complication due to inadvertent damage or removal of the parathyroid glands during surgery. Hypocalcemia can lead to neuromuscular irritability, including muscle twitching, tingling, or tetany.
A Nausea is a common postoperative symptom and can be caused by anesthesia, pain medications, or changes in gastrointestinal function. While uncomfortable, nausea alone is typically not an urgent concern
B Serosanguineous drainage (thin, pink-tinged fluid) from the surgical incision is expected in the early postoperative period. It indicates normal wound healing and does not usually require urgent attention
D. Routine incisional pain does not typically require urgent reporting unless accompanied by other concerning symptoms.
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