A nurse performs an integumentary assessment of a client who has recently fallen and broken his leg. The nurse notes the skin coloring on the broken leg is bluish gray. What is the term for this change in skin color?

A. Adequacy of circulation:

This assessment is the highest priority for a client who has undergone a procedure to bypass arteries in the right leg. Monitoring for signs of adequate blood flow, such as color, temperature, capillary refill, and pulses in the operated leg, is critical to identify and address any circulation issues early.

B. Patency of airway:

While maintaining a patent airway is always a priority in postoperative care, it is not the immediate concern in a client who has just undergone a leg bypass procedure. Airway management is essential, but assessing circulation in the operated limb takes precedence.

C. Movement of lower leg:

Assessing movement of the lower leg is important for detecting signs of impaired motor function or complications. However, it is secondary to assessing the adequacy of circulation, which is critical for preventing ischemia and other circulatory issues.

D. Neurovascular status of the left leg:

While monitoring the neurovascular status of the left leg is a valid aspect of the overall assessment, the priority in the immediate postoperative period is to assess the surgical site (right leg) to ensure that blood flow is adequate and that there are no immediate complications.

A. Check temperature and SPO2

When the nurse finds an adult patient's pulse rate to be 140 beats per minute, it is important to assess other vital signs, particularly temperature and oxygen saturation (SPO2). This helps gather additional information to understand the overall clinical picture and assess for potential underlying causes of the elevated heart rate.

B. Report the rate to the primary care provider:

Reporting the heart rate to the primary care provider may be necessary, but it should not be the immediate action. Assessing other vital signs first provides a more comprehensive understanding.

C. Check the pulse again in 2 hours:

Waiting for 2 hours to recheck the pulse is not appropriate when the heart rate is significantly elevated. Immediate action and further assessment are needed.

D. Record the information:

Recording the elevated heart rate is part of documentation, but it should be accompanied by a more comprehensive assessment of vital signs and potential contributing factors.