A client has just returned to the surgical unit following a femoral-popliteal bypass of the right leg. In which position should the nurse place the client?
Supine with the right leg extended and flat.
High-Fowler’s with the right leg extended.
Supine with the right leg flexed at a 45-degree angle.
Semi-Fowler’s with the right leg on two pillows.
The Correct Answer is A
Choice A rationale
After a femoral-popliteal bypass, the client should be placed in a supine position with the right leg extended and flat. This position helps to prevent kinking and occlusion of the graft, which could lead to complications such as graft thrombosis.
Choice B rationale
High-Fowler’s position with the right leg extended is not recommended. This position could put strain on the surgical site and potentially compromise the graft.
Choice C rationale
Supine with the right leg flexed at a 45-degree angle is not advised. Flexing the leg could lead to kinking of the graft and subsequent complications.
Choice D rationale
Semi-Fowler’s with the right leg on two pillows is not the optimal position. While elevation can help with swelling, excessive elevation could potentially compromise blood flow to the graft.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Assess for Red Man Syndrome. Vancomycin can cause a reaction known as Red Man Syndrome, which is characterized by flushing and/or an erythematous rash that affects the face, neck, and upper torso. This is not an allergic reaction, but rather a direct histamine-release effect of the drug.
Choice B rationale
Assess the client’s hearing. Ototoxicity, which can manifest as hearing loss, is a potential side effect of vancomycin. Therefore, it’s important to monitor the client’s hearing during treatment.
Choice C rationale
Obtain an arterial blood gas (ABG). This is not typically required when administering vancomycin. ABGs are usually drawn to assess a patient’s acid-base balance and oxygenation status, not as a routine part of vancomycin administration.
Choice D rationale
Infuse the drug over 1-2 hours. Vancomycin should be administered over at least 60 minutes to avoid skin irritation. Infusing the drug too quickly can also increase the risk of Red Man Syndrome.
Choice E rationale
Obtain an ordered trough level prior to next scheduled dose. Monitoring vancomycin trough levels is important to ensure therapeutic efficacy and to avoid toxicity. Trough levels are typically drawn just before the next dose is due.
Correct Answer is D
Explanation
Choice A rationale
The infectious agent is the pathogen that causes the disease, and the reservoir is where the infectious agent lives and multiplies. Hand washing does not directly intervene between these two links.
Choice B rationale
The mode of transmission is how the infectious agent travels to other people and places, and the portal of entry is the route by which an infectious agent enters a new host. Hand washing does not directly intervene between these two links.
Choice C rationale
The susceptible host is a person who is vulnerable to the disease, and the infectious agent is the pathogen that causes the disease. Hand washing does not directly intervene between these two links.
Choice D rationale
The portal of exit is the route by which an infectious agent escapes or leaves the reservoir, and the mode of transmission is how the infectious agent travels to other people and places. Hand washing directly intervenes between these two links by removing the infectious agent from the hands (portal of exit) and preventing its transmission to other people or surfaces.
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