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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

While children with eczema may have a weakened skin barrier, which can increase the risk of certain infections, there is no direct scientific link that statistically increases the risk of pneumonia specifically. Pneumonia is primarily a respiratory infection, whereas eczema is a dermatological condition.

Choice B rationale

Acne is a condition caused by the overproduction of sebum and clogged hair follicles, which typically occurs during puberty. There is no direct causal relationship or increased risk of developing acne in children with infantile eczema, which is an inflammatory skin condition.

Choice C rationale

Sun sensitivity is not an increased risk directly associated with infantile eczema. Eczema affects the skin's barrier function and immune response, but it does not inherently increase the skin's susceptibility to ultraviolet radiation. Some topical treatments, however, may cause photosensitivity.

Choice D rationale

Atopic dermatitis (eczema) is part of a triad of allergic conditions known as the "atopic march.”. This progression often starts with eczema in infancy, followed by food allergies, and later progresses to allergic rhinitis and asthma. This is due to a shared genetic predisposition and a hyper-responsive immune system.

A. Bathe the child using products with a light fragrance. B. Use oatmeal and baking soda as bath additives. C. Add bath oil to bath water after the child has soaked. D. Apply lanolin-based lotions after the bath.

Correct Answer is ["B","C"]

Explanation

Choice A rationale

Bathing a child with infantile eczema using products containing fragrance can be irritating to the already compromised skin barrier. Fragrances are common allergens and can trigger or worsen the inflammatory response in atopic dermatitis. It is essential to use fragrance-free, hypoallergenic products to minimize irritation and prevent exacerbations.

Choice B rationale

Using oatmeal and baking soda as bath additives can be soothing for the irritated skin of a child with infantile eczema. Colloidal oatmeal contains avenanthramides which have anti-inflammatory and antioxidant properties, while baking soda can help to relieve itching. These additives can help to calm the skin and reduce the urge to scratch.

Choice C rationale

Adding bath oil to bath water after the child has soaked for a period of time is a beneficial practice. Soaking in water allows the skin to rehydrate. Adding the oil at the end of the bath helps to seal in the moisture, forming a protective barrier and preventing transepidermal water loss, which is a key issue in eczema.

Choice D rationale

Lanolin is a fatty substance derived from sheep wool. While it can be a good moisturizer, it is also a common allergen. Applying lanolin-based lotions to a child with eczema can potentially trigger an allergic reaction or worsen the skin condition. It is safer to use hypoallergenic, non-irritating moisturizers.

Choice E rationale

Bathing a child several times a day can strip the skin of its natural oils, which can worsen the dryness and irritation associated with infantile eczema. The skin barrier is already compromised, and frequent bathing can exacerbate this problem. It is generally recommended to limit bathing to once a day or less to maintain skin integrity. .

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What risk is increased with children who have been diagnosed with infantile eczema?

Correct Answer is D

Explanation

A nurse is preparing a teaching plan for the care of a child with infantile eczema. What interventions would the nurse include? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

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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?