The nurse provides postoperative care to a patient who underwent peripheral artery bypass surgery. Thirty minutes after the initial assessment, the nurse reassesses the patient and detects a change in the Doppler sound over a pulse. Which action should the nurse take?
Contact the health care provider
Recheck the pulse in another 30 minutes
Measure the ankle-brachial index
Administer an oral anticoagulant
The Correct Answer is A
Choice A reason: Contacting the health care provider is the most appropriate action because a change in the Doppler sound may indicate a potential complication, such as graft occlusion or compromised blood flow. Immediate assessment and intervention by the health care provider are essential to prevent further complications and ensure the patient's safety.
Choice B reason: Rechecking the pulse in another 30 minutes is not advisable in this situation because it could delay necessary medical intervention. Prompt communication with the health care provider is crucial to address the underlying issue and provide timely care.
Choice C reason: Measuring the ankle-brachial index can provide valuable information about blood flow in the lower extremities, but it is not the immediate priority when a significant change in the Doppler sound is detected. Contacting the health care provider for further assessment and instructions takes precedence.
Choice D reason: Administering an oral anticoagulant is not an appropriate action without the direct instruction from a health care provider. The nurse must first report the change in the Doppler sound to the provider and follow their specific orders regarding medication and treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Improving public transportation to the clinic would indeed make it easier for residents to access healthcare services. However, this strategy alone does not directly address the cultural and specific health needs of the Hispanic community.
Choice B reason: Obtaining low-cost medications for clinic patients can alleviate some financial burdens and improve access to necessary treatments. While this is beneficial, it does not tackle the root of health disparities related to cultural differences and health beliefs.
Choice C reason: Teaching clinic staff about cultural health beliefs is crucial for reducing health care disparities and promoting health equity. Understanding the cultural background, health beliefs, and practices of the Hispanic community allows healthcare providers to deliver more culturally competent and patient-centered care, building trust and improving health outcomes.
Choice D reason: Updating equipment and supplies at the clinic can enhance the quality of care provided. However, without addressing the cultural competency of the healthcare staff, this strategy does not directly impact health equity or reduce disparities specific to the Hispanic community.
Correct Answer is C
Explanation
Choice A reason: Teaching the patient to use guided imagery can be an effective pain management strategy, but it might not be the most immediate and reassuring intervention for a patient experiencing fear about postoperative pain. This approach is more useful as an additional technique rather than the primary intervention.
Choice B reason: Describing the type of pain expected with the patient's particular surgery can provide some insight into what to anticipate, but it does not necessarily alleviate fear or provide concrete strategies for managing pain. It might even increase anxiety by focusing on the details of the pain itself.
Choice C reason: Explaining the pain management plan, including the use of a pain rating scale, is the most effective intervention. This approach directly addresses the patient's concerns by providing them with a clear understanding of how their pain will be managed and controlled postoperatively. Knowing that there is a structured plan in place, with specific methods to assess and manage pain, helps build confidence and reduces fear. The use of a pain rating scale also empowers the patient to communicate their pain levels effectively, ensuring timely and appropriate interventions.
Choice D reason: Informing the patient that pain medication will be available is helpful, but it lacks the detail and comprehensive approach of explaining the entire pain management plan. Patients may still have concerns about how their pain will be assessed and addressed specifically.
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