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 B
Explanation
Choice A reason: Nursing supervisors generally oversee nursing staff and ensure that patient care standards are being met, but they are not primarily responsible for developing individualized plans of care.
Choice B reason: Registered nurses (RNs) are trained and licensed to develop individualized plans of care that include nursing diagnoses, interventions, and outcomes. They work closely with patients to understand their needs and create a plan that supports their health goals, including self-management care.
Choice C reason: Health care providers, such as medical doctors (MDs) or nurse practitioners (NPs), are responsible for diagnosing and treating medical conditions, but the development of detailed nursing care plans is typically outside their primary scope of practice.
Choice D reason: Licensed practical/vocational nurses (LPN/VN) provide basic nursing care and assist with patient care activities, but they do not generally develop comprehensive nursing care plans, which require the higher level of training and education that RNs receive.
Correct Answer is B
Explanation
Choice A reason: Encouraging the patient to engage in strenuous exercise to improve circulation is not appropriate for someone with thrombocytopenia. Strenuous exercise can increase the risk of injury and bleeding, which is particularly dangerous for patients with a low platelet count.
Choice B reason: Instructing the patient to use an electric razor for shaving is the most appropriate intervention. Thrombocytopenia increases the risk of bleeding, and using an electric razor instead of a traditional blade helps minimize the risk of cuts and subsequent bleeding.
Choice C reason: Teaching the patient to use a water pick for oral hygiene is not recommended for thrombocytopenia patients. Water picks can cause bleeding of the gums, which is a concern for individuals with low platelet counts. Using a soft-bristled toothbrush is safer.
Choice D reason: Requesting an order for subcutaneous heparin to prevent blood clots is not advisable for a thrombocytopenia patient without specific medical indication. Heparin is an anticoagulant, and administering it to someone with low platelets can exacerbate the risk of bleeding.
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