The nurse is caring for a client who is two days post-aortic-iliac bypass surgery. Which assessment finding should be reported to the surgeon immediately?
Blood pressure of 98/60.
Urine output of 40 mL/hour.
Pain rated as 5 on a 0-10 scale.
Absence of popliteal pulse.
The Correct Answer is D
Choice A Reason:
A blood pressure of 98/60, while on the lower side, is not necessarily alarming post-surgery unless the patient shows symptoms of hypotension or if there is a significant drop from the patient's baseline blood pressure. It is important to monitor trends in blood pressure readings rather than a single isolated measurement.
Choice B Reason:
A urine output of 40 mL/hour can be considered within normal limits post-surgery, as the expected urine output is at least 0.5 mL/kg/hr. However, it should be monitored closely to ensure that it does not decrease further, which could indicate renal complications.
Choice C Reason:
Pain rated as 5 on a 0-10 scale indicates moderate pain, which is expected post-surgery. Pain management should be continued as prescribed, and the patient should be reassessed regularly to ensure that the pain does not escalate.
Choice D Reason:
The absence of a popliteal pulse is a critical finding that must be reported immediately. The popliteal artery provides blood flow to the lower leg, and its absence could indicate graft occlusion or other serious circulatory issues, which could lead to limb-threatening complications if not addressed promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason
While maintaining a stable blood pressure is important for a client with hypertension, furosemide is primarily a diuretic, and its therapeutic effect is to reduce fluid overload, not directly to stabilize blood pressure. Therefore, this finding alone does not best indicate the therapeutic effect of furosemide.
Choice B Reason
Clear lungs upon auscultation suggest an improvement in pulmonary edema, which can be associated with fluid overload in conditions such as heart failure. However, for a client with peripheral edema, the primary therapeutic goal of furosemide is to reduce the excess fluid in the extremities, not just the lungs.
Choice C Reason
A decrease in serum potassium is a known side effect of furosemide due to its action on the kidneys, leading to increased excretion of potassium. While it's important to monitor for hypokalemia, a decrease in potassium does not directly indicate the therapeutic effect of reducing edema.
Choice D Reason
An increase in urine output from 30 mL per hour to 100 mL per hour is a direct indication that furosemide is achieving its therapeutic effect. Furosemide is a loop diuretic that increases urine production to help the body eliminate excess fluid, thereby reducing edema associated with conditions like hypertension.
Correct Answer is B
Explanation
Choice a reason:
A cream to soothe itching may be used if the client is experiencing pruritus, which can sometimes accompany biliary issues due to bile salts in the skin. However, pruritus is not a direct symptom of biliary colic, which is characterized primarily by pain.
Choice b reason:
Pain medication is the appropriate treatment for biliary colic. Biliary colic is caused by the temporary blockage of the bile duct by a gallstone, leading to intense pain in the upper right abdomen or the center of the abdomen. Pain relief is typically achieved with anti-inflammatory drugs or antispasmodics, and in some cases, opioids may be necessary.
Choice c reason:
An antibiotic would be prescribed if there was an infection, such as cholecystitis or cholangitis. Biliary colic itself does not necessarily indicate an infection unless accompanied by other symptoms such as fever or elevated white blood cell count.
Choice d reason:
A laxative is not typically used to treat biliary colic. While laxatives can help relieve constipation, biliary colic is a result of gallstones obstructing the bile duct, not bowel movement issues.
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