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

Answer and Explanation

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.

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Correct Answer is ["C","D"]

Explanation

Choice A reason: Placing the patient in restraints for safety is not typically necessary unless the patient is agitated or a danger to themselves or others. This action is not directly addressing the acute condition of a stroke.

Choice B reason: Inserting an NGT (nasogastric tube) is not an immediate priority in the acute management of a stroke. This might be considered later if the patient has swallowing difficulties and needs nutritional support, but it is not a first-line intervention.

Choice C reason: Anticipating thrombolytic therapy for ischemic stroke is appropriate, as timely administration of thrombolytics can dissolve the clot and improve blood flow to the affected brain area, potentially reducing the severity of the stroke.

Choice D reason: Establishing IV access with normal saline is crucial for administering medications and maintaining hydration. It ensures that the patient can receive necessary interventions promptly.

Choice E reason: Placing the patient in the prone position is not appropriate in the management of an acute stroke. The prone position is generally used in respiratory conditions to improve oxygenation but is not relevant to stroke management.

A. Monitor the patient for shortness of breath or chest pain during the transfusion B. Obtain the patient's temperature and blood pressure before the transfusion C. Double-check the product numbers on the PRBCs with the patient ID band

Correct Answer is B

Explanation

Choice A reason: Monitoring the patient for shortness of breath or chest pain during the transfusion is a critical task that requires nursing judgment and immediate intervention if complications arise. It is not appropriate to delegate this task to unlicensed assistive personnel.

Choice B reason: Obtaining the patient's temperature and blood pressure before the transfusion is a task that can be safely delegated to nursing assistants. This task does not require the clinical judgment of a licensed nurse and is within the scope of practice for unlicensed assistive personnel.

Choice C reason: Double-checking the product numbers on the PRBCs with the patient ID band is a crucial safety step that must be performed by licensed nursing staff. This task ensures the correct blood product is given to the correct patient and involves verification that cannot be delegated to unlicensed personnel.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","D"]

Explanation

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from a gastrointestinal hemorrhage. Which action can the nurse delegate to the nursing assistant (unlicensed assistive personnel)?

Correct Answer is B

Explanation

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