The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take first?
Wrap both legs in a warming blanket
Compare findings to the preoperative assessment of the pulses
Document the findings and recheck in 15 minutes.
Notify the surgeon and anesthesiologist
The Correct Answer is D
The nurse should prioritize notifying the surgeon and anesthesiologist as the first action. The absent pulses, coolness, and mottled appearance of the leg indicate potential compromised blood flow to the lower extremity, which could be a sign of vascular compromise or acute limb ischemia. These findings are concerning after the repair of an abdominal aortic aneurysm and require immediate medical attention.
Wrap both legs in a warming blanket: While it is important to maintain the client's body temperature, this action alone may not address the underlying issue of compromised blood flow and potential limb ischemia. Notifying the surgeon and anesthesiologist is the priority to address the immediate concern.
Compare findings to the preoperative assessment of the pulses: While comparing findings to the preoperative assessment is important for evaluating the client's condition, it should not delay immediate action. The priority in this situation is to promptly notify the surgeon and anesthesiologist to address the potential vascular compromise.
Document the findings and recheck in 15 minutes: Documenting the findings is an important step in the nursing process, but it should not take precedence over immediate intervention. The concerning signs of absent pulses, coolness, and mottled appearance require urgent attention, and delaying notification could lead to further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The procedure uses electrical energy to destroy areas of the conduction system: Catheter ablation is a minimally invasive procedure performed to treat abnormal heart rhythms, such as atrial flutter. During the procedure, a catheter is inserted into the heartand used to deliver electrical energy to specific areas of the heart tissue. This energy is used to destroy or ablate the abnormal conduction pathways that are causing the atrial flutter.
Let's go through the other options and explain why they are not accurate:
The procedure stimulates the growth of new pathways between the atria: Catheter ablation does not stimulate the growth of new pathways. Instead, it aims to eliminate or modify existing abnormal pathways in the heart to restore normal electrical conduction.
The procedure uses cold therapy to stop the formation of the flutter waves: Catheter ablation does not use cold therapy. It primarily utilizes radiofrequency energy or other sources of heat to ablate the targeted areas of the heart tissue.
The procedure prevents or minimizes the patient's risk for sudden cardiac death: While catheter ablation can be an effective treatment for certain arrhythmias, including atrial flutter, it is not primarily performed to prevent or minimize the risk of sudden cardiac death. Its main purpose is to restore normal heart rhythm and alleviate symptoms associated with the arrhythmia.
Correct Answer is D
Explanation
Helping to position a client for a portable x-ray generally involves physically assisting the client in moving into the appropriate position or adjusting their body as needed. This task can be safely delegated to the UAP as long as they have received proper training on how to safely assist with positioning and have a clear understanding of the specific instructions provided by the radiology department.
Assisting the client to take the beta-blocker involves administering medication, which falls within the scope of nursing practice and requires the nurse's expertise in medication administration and monitoring the client's response.
Transporting the client to the intensive care unit via a stretcher involves moving the client to another unit and may require additional monitoring and coordination of care during the transfer. This task is best performed by the nurse, who can assess the client's stability, ensure appropriate documentation, and communicate effectively with the receiving unit.
Providing discharge-teaching instructions to the client going home requires the nurse to provide information about medications, wound care, follow-up appointments, and other important instructions. This task involves comprehensive education and assessment ofthe client's understanding, and is best performed by the nurse to ensure accurate and complete information is provided.
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