Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?
Elevate extremities on pillows.
Evaluate edema for pitting.
Wrap the feet with warmed blankets.
Assess pulses with a vascular Doppler
The Correct Answer is D
A. Elevate extremities on pillows:
While elevation can be beneficial for reducing dependent edema, the priority is to assess the pulses first to determine the adequacy of peripheral perfusion.
B. Evaluate edema for pitting:
Assessing edema for pitting is important for gathering additional information, but it is not the initial action in this scenario. Assessing pulses is more critical to evaluate perfusion.
C. Wrap the feet with warmed blankets:
Warming the feet with blankets may be appropriate in some situations, but it is not the priority when the client is exhibiting edema and non-palpable pedal pulses. The primary concern is assessing perfusion.
D. Assess pulses with a vascular Doppler:
This is the correct action. The non-palpable pedal pulses are concerning and require immediate assessment to determine the status of peripheral perfusion. Using a vascular Doppler will help the nurse assess the presence or absence of blood flow in the lower extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Encourage regular turning:
While turning is important for preventing complications like pressure ulcers, in this acute situation, addressing fluid imbalance and potential sepsis take precedence.
B. Monitor skin for breakdown:
Monitoring for skin breakdown is essential but is not the most critical intervention at this moment.
C. Assess wound drainage daily:
Daily assessment of wound drainage is important for evaluating the status of the surgical site. However, in this situation of potential anastomosis leakage with signs of systemic infection and hypotension, immediate interventions to stabilize the client's condition are of higher priority.
D. Strict IV fluid replacement:
This is the correct answer. The client is displaying signs of systemic infection (fever) and possible sepsis (tachycardia, hypotension), which might be due to an anastomosis leakage following gastric bypass surgery. Ensuring adequate IV fluid replacement is crucial to address hypotension, maintain perfusion, and support hemodynamic stability in this critical situation.
Correct Answer is C
Explanation
A. Facial puffiness and periorbital edema:
These are common signs of hypothyroidism but may not require immediate action unless accompanied by severe symptoms.
B. Cold and dry skin:
Cold and dry skin is a characteristic feature of hypothyroidism, but a further decline in the level of consciousness is a more urgent issue.
C. Further decline in the level of consciousness.
A decline in the level of consciousness is a critical sign that requires immediate attention, as it may indicate worsening hypothyroidism, myxedema coma, or other serious complications. Myxedema coma is a life-threatening condition associated with severe hypothyroidism, and it requires prompt medical intervention.
D. Hematocrit of 30% (0.30):
While anemia is a potential complication of hypothyroidism, a hematocrit of 30% alone may not be the most immediate concern compared to a decline in the level of consciousness.
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