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 D

Explanation

Choice A reason: Preventing skin maceration is not the primary purpose of the reverse Trendelenburg position. Skin maceration typically occurs due to excessive moisture on the skin, and the bed position does not directly address this issue.

Choice B reason: Reducing restenosis, which is the re-narrowing of a blood vessel after it has been treated, is not directly affected by the patient's bed position. Restenosis is more related to the procedure performed and the patient's overall condition rather than positioning.

Choice C reason: Reducing the risk of infection is also not a direct benefit of the reverse Trendelenburg position. Infection prevention involves maintaining sterile techniques, proper wound care, and monitoring for signs of infection.

Choice D reason: Increasing perfusion to the legs is the correct rationale for placing the bed in the reverse Trendelenburg position for a patient with critical limb ischemia. This position helps to improve blood flow to the lower extremities by utilizing gravity to aid in circulation, thus enhancing oxygen and nutrient delivery to the affected tissues.

A. Hypotension, chills, thirst B. Lethargy, confusion, bradycardia C. Bradycardia, hypotension, low urine output D. Fever, tachycardia, tremors

Correct Answer is D

Explanation

Choice A reason: Hypotension, chills, and thirst are not characteristic signs and symptoms of a thyroid storm. Hypotension generally indicates low blood pressure, while chills and thirst are less specific symptoms that do not particularly point to thyroid storm.

Choice B reason: Lethargy, confusion, and bradycardia are not typical indicators of a thyroid storm. These symptoms might be present in other conditions but are not generally associated with the severe hypermetabolic state seen in thyroid storms.

Choice C reason: Bradycardia, hypotension, and low urine output are also not typical signs of a thyroid storm. Bradycardia (slow heart rate) and hypotension (low blood pressure) are more likely associated with severe hypothyroidism or other conditions, not the hyperactive state of a thyroid storm.

Choice D reason: Fever, tachycardia, and tremors are classic signs of a thyroid storm. A thyroid storm is a life-threatening condition characterized by an excessive amount of thyroid hormones, leading to hypermetabolic activity. This results in symptoms like a high fever, rapid heart rate (tachycardia), and tremors.

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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

Which rationale supports placing the bed in the reverse Trendelenburg position for a patient with critical limb ischemia?

Correct Answer is D

Explanation

Adlent has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder?

Correct Answer is D

Explanation

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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?

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