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. Providing the client with a trapeze bar allows them to move and reposition in bed independently without compromising the traction on the affected leg.
A Checking pressure points every 2 hours is generally recommended for clients at risk of developing pressure ulcers, but it's not specific to skeletal traction care.
C. Removing the weights prematurely can lead to loss of traction and compromise the therapeutic benefit of the traction.
D. When a client has skeletal traction, they should avoid using the affected limb for any weight-bearing activities or for repositioning
Correct Answer is A
Explanation
A. Nuchal rigidity refers to stiffness or resistance to neck movement, especially when the client's head is flexed forward. It is a classic sign of meningitis due to irritation and inflammation of the meninges (the membranes surrounding the brain and spinal cord). This assessment helps to detect meningeal irritation, a hallmark of meningitis.
B. This action tests the deep tendon reflex, specifically the knee jerk reflex (patellar reflex). It assesses the integrity of the spinal cord and peripheral nerves. While it is part of a neurological assessment, it is not specifically related to the assessment of meningitis unless there are concurrent neurological symptoms or signs.
C This maneuver tests for Babinski reflex, which is an abnormal response where the toes flare upward and the big toe dorsiflexes when the sole of the foot is stimulated. A positive Babinski reflex can indicate dysfunction of the corticospinal tract or brain injury but is not a specific finding in meningitis.
D. Tapping the facial nerve (cranial nerve VII) assesses for the presence of facial nerve irritation or damage. In the context of meningitis, signs such as facial twitching or asymmetry may indicate involvement of cranial nerves due to inflammation and pressure within the skull.
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