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 C

Explanation

Choice A rationale

A Braden Scale score of 9 indicates a high risk for pressure injury. Requesting a referral to a registered dietitian nutritionist is an evidence-based intervention because poor nutrition, particularly protein and calorie deficiency, is a significant risk factor for skin breakdown and impaired wound healing.

Choice B rationale

Keeping the head of the bed raised no more than 45 degrees is an evidence-based practice to prevent pressure injuries. This position reduces the risk of shear and friction forces on the sacrum, which can lead to tissue damage and pressure ulcer formation.

Choice C rationale

Performing perineal cleansing every 2 hours is not an evidence-based intervention for a Braden Scale score of 9. Frequent cleansing can cause excessive moisture, which macerates the skin and increases the risk of breakdown. Cleansing should be done as needed, not on a rigid schedule.

Choice D rationale

Daily skin assessment is a fundamental and evidence-based intervention for all clients at risk for pressure injuries. A Braden score of 9 signifies a high-risk client, and a daily head-to-toe skin assessment is crucial for early detection of erythema or other signs of skin breakdown.

A. "The wound edges have been approximated and stitched together.”. B. "The wound was stapled together after an infection was cleared up.”. C. "The wound is an open cavity that will fill in with granulation tissue.”. D. "The wound was contaminated by debris and cannot be closed at all.”.

Correct Answer is C

Explanation

Choice A rationale

Healing by primary intention, also known as primary union, occurs when a wound has clean edges that are approximated and sutured, stapled, or glued together. This process minimizes tissue loss and results in a fine scar. The wound's integrity is re-established with minimal granulation tissue formation.

Choice B rationale

This describes a form of delayed primary closure or tertiary intention healing. The wound is initially left open to allow for drainage and to clear infection. Once the wound is considered clean and free of infection, the edges are then approximated and closed, often with staples, to promote healing.

Choice C rationale

Healing by secondary intention, or secondary union, occurs in large, open wounds with significant tissue loss and non-approximated edges. The wound heals from the base up. This process involves the formation of new connective tissue and capillaries, called granulation tissue, to fill the defect before epithelialization can occur.

Choice D rationale

While contaminated wounds can heal by secondary intention, this description is not a complete definition. Secondary intention healing is a specific biological process involving granulation tissue, not just a description of a wound that is open due to contamination or debris. The defining characteristic is the formation of granulation tissue.

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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

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Correct Answer is C

Explanation

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Correct Answer is 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?