A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?
The client's foot feels cooler than in the previous assessment.
The client's pedal pulse in the right foot is not palpable.
The client's capillary refill time is 5 seconds in the toes.
The client reports a pain level of 8 on a scale from 0 to 10.
The Correct Answer is B
The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood flow to the limb.
The other options are also concerning and should be reported to the healthcare provider.
a) A cooler foot may indicate decreased blood flow to the limb.
c) A capillary refill time of 5 seconds may also indicate decreased blood flow.
d) A pain level of 8 on a scale from 0 to 10 should also be reported and addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct technique for using an albuterol MDI involves closing the mouth around the mouthpiece to create a seal. This helps ensure that the medication is delivered directly into the lungs and maximizes its effectiveness. It also helps prevent the medication from escaping and being wasted.
"Exhale immediately after inhaling": This instruction is not accurate. After closing the mouth around the mouthpiece and activating the inhaler to release the medication, the client should inhale slowly and deeply through the mouth, holding their breath for about 10 seconds if possible. Exhaling immediately after inhaling would not allow enough time for the medication to be absorbed effectively.
"Tilt your head forward while inhaling": Tilted head position is not necessary when using an albuterol MDI. The client should hold the inhaler in an upright position, with the mouthpiece directed toward their mouth. This allows for proper delivery of the medication.
"Take three quick breaths while depressing the canister": This instruction is not accurate for using an albuterol MDI. The correct technique involves taking a slow and deep breath in through the mouth, while simultaneously depressing the canister to release the medication. Taking three quick breaths may not allow enough time for adequate medication delivery.
Correct Answer is ["A","B","E"]
Explanation
Compartment syndrome is a condition characterized by increased pressure within a closed anatomical space, such as a compartment in the leg. This increased pressure can compromise blood flow and nerve function. When assessing a client with a long-leg cast who reports severe pain, the nurse should be vigilant for signs and symptoms of compartment syndrome.
Option a is a correct answer because pallor (paleness) in the exposed portion of the left foot may indicate compromised blood flow due to increased pressure within the compartment.
Option b is a correct answer because the inability to move the left foot suggests impaired nerve function,
which can be a sign of compartment syndrome.
Option c is not a correct answer. Increased warmth is not typically associated with compartment syndrome; instead, it may suggest inflammation or infection.
Option d is not a correct answer. Ecchymosis (bruising) is not typically associated with compartment syndrome, as it is more commonly observed in cases of injury or trauma.
Option e is a correct answer because paresthesia (abnormal sensations like tingling or numbness) in the left foot can indicate nerve compression and is a potential symptom of compartment syndrome.
By identifying the presence of pallor, inability to move the foot, and paresthesia, the nurse can recognize indications of compartment syndrome and take appropriate actions to address the condition promptly.
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