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 D
Explanation
D. Naloxone competitively binds to opioid receptors, displacing opioids from these receptors and rapidly reversing their effects. It is the drug of choice for managing opioid-induced respiratory depression and is administered to restore adequate ventilation and prevent respiratory arrest.
A Diphenhydramine is an antihistamine with sedative properties. It is used primarily for allergic reactions and as a sleep aid. Diphenhydramine is not indicated for reversing respiratory depression caused by opioid overdose. It does not antagonize opioid receptors or reverse the effects of opioids.
B. Flumazenil is not effective in reversing respiratory depression caused by opioid overdose. It does not affect opioid receptors or reverse the respiratory depressant effects of opioids.
C. Calcium gluconate is a form of calcium used to treat hypocalcemia or to counteract the cardiac effects of hyperkalemia. It does not reverse opioid-induced respiratory depression. It is not indicated in this situation.
Correct Answer is A
Explanation
A Nitroglycerin is a vasodilator that helps relieve angina by dilating blood vessels and increasing blood flow to the heart muscle. It is typically the first-line medication for acute angina attacks. Administering nitroglycerin promptly can help alleviate the client's pain and prevent progression to a myocardial infarction (heart attack).
B. Aspirin is often administered to clients with suspected myocardial ischemia or infarction because it inhibits platelet aggregation, which can reduce the risk of clot formation and further occlusion of coronary arteries. It is typically given early in the management of acute coronary syndrome to prevent clotting complications.
C. While monitoring blood pressure is important in clients with acute angina, especially to assess for hypotension which could indicate cardiogenic shock, it is not the first action. Immediate pain relief and prevention of further ischemic damage take precedence over blood pressure measurement.
D. IV access is important for administering medications and fluids if needed, but it is not the first priority unless the client's condition warrants immediate IV medication administration (such as in severe pain or impending myocardial infarction).
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.