A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to bypass arteries in the right leg. Which assessment should receive the highest priority?
Adequacy of circulation
Patency of airway
Movement of lower leg
Neurovascular status of the left leg
The Correct Answer is A
A. Adequacy of circulation:
This assessment is the highest priority for a client who has undergone a procedure to bypass arteries in the right leg. Monitoring for signs of adequate blood flow, such as color, temperature, capillary refill, and pulses in the operated leg, is critical to identify and address any circulation issues early.
B. Patency of airway:
While maintaining a patent airway is always a priority in postoperative care, it is not the immediate concern in a client who has just undergone a leg bypass procedure. Airway management is essential, but assessing circulation in the operated limb takes precedence.
C. Movement of lower leg:
Assessing movement of the lower leg is important for detecting signs of impaired motor function or complications. However, it is secondary to assessing the adequacy of circulation, which is critical for preventing ischemia and other circulatory issues.
D. Neurovascular status of the left leg:
While monitoring the neurovascular status of the left leg is a valid aspect of the overall assessment, the priority in the immediate postoperative period is to assess the surgical site (right leg) to ensure that blood flow is adequate and that there are no immediate complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Performs auscultation between meals:
Auscultating bowel sounds between meals is suitable as it allows for better detection of bowel sounds when digestion is not actively occurring.
B. Clamps the Naso Gastric tube during auscultation
Clamping the Naso Gastric (NG) tube during auscultation is appropriate. The NG tube when unclamped allows the free passage of air and fluid through the gastrointestinal tract. This could interfere with the natural sounds produced by the movement of air and fluid in the intestines, potentially leading to inaccurate assessment of bowel sounds.
C. Palpates the abdomen prior to performing auscultation:
Palpating the abdomen before auscultation may interfere with normal bowel sounds
D. Auscultates bowel sounds for 3 to 5 min:
Auscultating bowel sounds for a sufficient duration (3 to 5 minutes) is appropriate to comprehensively assess the presence, frequency, and character of bowel sounds.
Correct Answer is A
Explanation
A. Take the blood pressure:
Assessing blood pressure is a critical initial step when a patient is experiencing dyspnea. It helps provide information about the patient's overall cardiovascular status, which is essential in determining the severity of the dyspnea and guiding subsequent interventions.
B. Remove the pillow from under the patient’s head:
Removing the pillow may be a relevant intervention if the patient is in a position that could be contributing to respiratory distress. However, the priority is to first assess vital signs, particularly blood pressure, to gather information about the patient's cardiovascular status.
C. Elevate the foot of the bed:
Elevating the foot of the bed may be a consideration if the dyspnea is related to conditions such as heart failure, where raising the legs can help reduce venous return and decrease the workload on the heart. However, the initial priority is to assess blood pressure to guide appropriate interventions.
D. Elevate the head of the bed:
Elevating the head of the bed may be beneficial for patients with respiratory distress to improve ventilation and oxygenation. While this intervention may be appropriate, the first action should be to assess vital signs, particularly blood pressure, to gain an overall understanding of the patient's condition.
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