A client is 4 hours postoperative after a femoral-popliteal bypass.
The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse is most important?
Administer pain medication as ordered.
Assess distal pulses and skin color.
Document the findings in the client's chart.
Notify the surgeon immediately.
The Correct Answer is B
Choice A rationale
Administering pain medication addresses the subjective symptom but does not address the underlying physiological cause, which could be a critical limb-threatening complication like acute limb ischemia. The priority is to assess for objective signs of vascular compromise to ensure the graft's patency and prevent irreversible tissue damage from prolonged ischemia.
Choice B rationale
Assessing distal pulses and skin color is the most critical action to evaluate the patency of the newly created bypass graft. A sudden decrease in blood flow, indicated by diminished pulses and pallor, is a sign of graft occlusion, which is a surgical emergency requiring immediate intervention to restore perfusion and prevent tissue necrosis.
Choice C rationale
Documenting the findings is an essential step in the nursing process, but it is not the most important immediate action. Documentation should follow a thorough assessment and any necessary interventions. Failure to assess the graft's patency first could delay a time-sensitive intervention and lead to irreversible limb damage.
Choice D rationale
Notifying the surgeon is a necessary step if objective signs of graft occlusion are found. However, this action should follow a focused assessment. The nurse must first gather objective data, such as pulse quality and skin color, to provide a complete and accurate report to the surgeon, guiding their decision-making process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Wet-to-damp saline moistened gauze is a method of debridement and is not the most effective choice for a wound with copious exudate. This dressing type is less absorbent and would quickly become saturated, requiring frequent changes. Frequent changes and wetness can lead to periwound skin maceration and irritation, hindering the healing process.
Choice B rationale
Leaving a stage 3 pressure injury open to the air is contraindicated. A stage 3 pressure injury involves full-thickness skin loss and is susceptible to infection. Leaving the wound open would not manage the copious exudate, would expose the wound bed to pathogens, and would lead to dehydration of the wound bed, which impairs cellular migration and proliferation necessary for healing.
Choice C rationale
A transparent film is a moisture-retaining dressing that is inappropriate for a wound with copious exudate. This dressing is designed for superficial wounds with minimal exudate. Applying a transparent film to a heavily draining wound would lead to the accumulation of exudate underneath the dressing, causing maceration of the surrounding skin and potential for infection.
Choice D rationale
A multi-fiber superabsorbent dressing is the most appropriate choice for a stage 3 pressure injury with copious exudate. These dressings are designed to absorb large volumes of fluid, wicking it away from the wound bed and periwound skin. This action helps to manage moisture, protect the surrounding skin from maceration, and maintain a moist environment ideal for wound healing.
Correct Answer is C
Explanation
Choice A rationale
Tazarotene, a retinoid, increases photosensitivity by thinning the stratum corneum, the skin's outermost layer. This reduces the protective barrier against ultraviolet (UV) radiation, making the skin more susceptible to sunburn and UV-induced DNA damage. Patients must be educated to use sun protection, but it is not the most critical question.
Choice B rationale
While a history of skin cancer can influence dermatological treatment plans, it is not the primary contraindication for tazarotene. Tazarotene is an analog of vitamin A, and its mechanism involves regulating cell proliferation and differentiation, which is not directly related to a personal or family history of skin cancer.
Choice C rationale
Tazarotene is a potent teratogen, meaning it can cause severe congenital malformations if taken during pregnancy. This teratogenic risk necessitates that all female patients of child-bearing potential use reliable contraception to prevent pregnancy. A pregnancy test is also required before initiation of therapy.
Choice D rationale
While some medications interact with alcohol, tazarotene is a topical retinoid primarily metabolized in the liver to its active form, tazarotenic acid. There is no significant systemic absorption or direct interaction with alcohol consumption that would cause a major adverse effect, making it a less critical question than contraception.
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