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 A
Explanation
The information that the nurse should include in the teaching plan for a client with hypertension who is on alpha blockers and at risk for postural hypotension is: Change positions slowly.
Alpha blockers are a class of medications commonly prescribed for hypertension. One potential side effect of alpha blockers is postural hypotension, which is a sudden drop in blood pressure when changing positions, such as from sitting to standing. To minimize the risk of postural hypotension, it is important for the client to change positions slowly. The nurse should advise the client to take their time when transitioning from lying down, sitting, or standing, allowing their body to adjust and stabilize their blood pressure.
The other options are not appropriate or helpful in managing postural hypotension:
Check blood pressure every day for signs of rebound hypertension: Rebound hypertension refers to a sudden increase in blood pressure that can occur when discontinuing certain antihypertensive medications. It is not directly related to postural hypotension. Regular blood pressure monitoring is important for managing hypertension, but it is not specifically related to postural hypotension or alpha blockers.
Do not become dependent on canes, walkers, or handrails: Assistive devices like canes, walkers, or handrails can provide support and stability for individuals who experience balance issues or are at risk of falls. It is not necessary to discourage their use unless there are specific contraindications or safety concerns.
Eat plenty of salty food to prevent hypotension: Increasing salt intake is generally not recommended for individuals with hypertension or those at risk of postural hypotension. A high-sodium diet can contribute to elevated blood pressure and is generally discouraged. The nurse should instead encourage a balanced diet that includes appropriate sodium intake based on the client's healthcare provider's recommendations.
Correct Answer is D
Explanation
Hydrochlorothiazide is a diuretic medication commonly prescribed for hypertension. It works by increasing urine output, which helps to reduce fluid volume and lower blood pressure. Taking the medication in the morning is beneficial because the increased urine production during the day can help prevent nighttime disruptions due to frequent urination.
Let's go through the other statements and explain why they are not accurate:
"I will not take this medicine when my blood pressure is okay":
This statement indicates a misunderstanding about the purpose of hydrochlorothiazide. It is important to take prescribed medications consistently, even when blood pressure readings are within the normal range, as they are intended to help maintain blood pressure control.
"I will check blood pressure in both arms and legs before taking the drug":
Checking blood pressure in both arms and legs is not directly related to hydrochlorothiazide use. Blood pressure should be monitored regularly, but it is not necessary to perform these measurements specifically before taking the medication.
"I will decrease potassium foods such as bananas in my diet":
Hydrochlorothiazide can cause potassium loss as a side effect. However, reducing potassium-rich foods without healthcare provider guidance may not be appropriate. It is important for the client to discuss dietary adjustments and potassium supplementation with their healthcare provider if needed.
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