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 C
Explanation
Answer: C. Weigh the client each morning after voiding
Rationale:
A. Encourage the client to gain 2.3 kg (5 lb) per week:
A weight gain goal of 0.5 to 1 kg (1 to 2 lb) per week is considered safe and realistic. Gaining 2.3 kg (5 lb) weekly is too aggressive and may cause physical and psychological stress for the client.
B. Monitor the client for 15 min after meals:
Clients with anorexia nervosa are at risk for purging behaviors. Monitoring for only 15 minutes is insufficient. A 60-minute post-meal observation period is more appropriate to deter vomiting or excessive exercise.
C. Weigh the client each morning after voiding:
Daily weights, taken at the same time each morning after voiding and before eating, provide consistent and accurate data to monitor progress and detect manipulation or fluid shifts.
D. Reinforce teaching about healthy eating during meals:
Reinforcing education during meals can increase the client’s anxiety and resistance to eating. Teaching is best done separately from mealtimes to avoid associating eating with stress.
Correct Answer is B
Explanation
The nurse should include increased cardiac output as an expected effect of digoxin when reinforcing teaching with the client. Digoxin is a positive inotropic medication that strengthens the force of contraction of the heart, resulting in increased cardiac output.
Option a, increased heart rate, is not an expected effect of digoxin. Digoxin may actually decrease heart rate by exerting a negative chronotropic effect.
Option c, decreased urinary output, is not an expected effect of digoxin. In fact, digoxin does not directly affect urinary output.
Option d, decreased potassium level, is not an expected effect of digoxin. However, digoxin can increase the risk of hypokalemia, so it is important to monitor the client's potassium levels while on the medication.
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