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 B
Explanation
Abdominal aortic aneurysms (AAA) often do not present with specific symptoms in the early stages. It is not uncommon for individuals with AAA to be asymptomatic or have vague symptoms. Therefore, the absence of abdominal pain or any problems related to the abdomen is a common finding during the assessment of a client with an abdominal aortic aneurysm.
Let's briefly review the other statements:
"I have stomach pain every time I eat a big, heavy meal": This statement is more suggestive of gastrointestinal issues such as indigestion or acid reflux rather than specifically related to an abdominal aortic aneurysm.
"I have periodic episodes of constipation and then diarrhea": This statement may indicate gastrointestinal issues, but it is not a typical symptom associated with an abdominal aortic aneurysm. AAA is primarily related to the aorta, the main blood vessel in the abdomen, and its symptoms are not directly linked to bowel function.
"I belch a lot, especially when I lay down after eating": This statement suggests gastrointestinal symptoms such as acid reflux or gastroesophageal reflux disease (GERD). While these symptoms may be unrelated to the abdominal aortic aneurysm itself, they can coexist with other conditions.
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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