A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the ﬁrst postoperative day?

Assess pulse of affected extremity every 15 minutes at ﬁrst.

Palpate the affected leg for pain during every assessment

Assess the client for signs and symptoms of compartment syndrome every 2 hours.

Perform Doppler evaluation once daily.

Answer and Explanation

Correct Answer : A,B,C,D

Assess pulse of the affected extremity every 15 minutes at ﬁrst: Frequent assessment of the pulse in the affected extremity is important to monitor for any changes in blood ﬂow. This allows the nurse to identify any potential complications such as graft occlusion or compromised circulation promptly.

Palpate the affected leg for pain during every assessment: Assessing for pain in the affected leg is crucial to identify any signs of ischemia or inadequate perfusion. Increased pain could indicate reduced blood ﬂow or other complications that require immediate attention.

Assess the client for signs and symptoms of compartment syndrome every 2 hours: Compartment syndrome can occur after vascular surgeries, and early recognition is vital. The nurse should assess for signs and symptoms such as pain, numbness, tingling, increased swelling, and tense compartments. Regular assessment every 2 hours can help detect compartment syndrome promptly and prevent further complications.

Perform Doppler evaluation once daily: Doppler evaluation may be ordered by the healthcare provider to assess blood ﬂow and graft patency. However, the frequency of Doppler evaluation may vary depending on the client's condition and the healthcare provider's orders. Once daily assessment is not suﬃcient if there are concerns regarding blood ﬂow or graft viability.

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

Explanation

Pain level of 10 out of 10: Severe pain can stimulate the sympathetic nervous system and result in an increased heart rate.

Temperature 101.9°F: Fever can lead to an elevated heart rate as the body's response to infection or inﬂammation.

Hemoglobin: 7 g/dL: Low hemoglobin levels, known as anemia, can cause the heart to pump faster in an attempt to compensate for the decreased oxygen-carrying capacity of the blood.

Cocaine abuse: Cocaine is a stimulant drug that can signiﬁcantly increase heart rate and cause tachycardia.

The following clinical ﬁnding would not typically be associated with tachycardia:

Blood glucose 90 mg/dL: While low or high blood glucose levels can cause symptoms, they are not directly associated with tachycardia unless they lead to signiﬁcant physiological stress or hormonal imbalances.

A. Shortness of breath. B. Abdominal bruit. C. Ripping abdominal pain. D. Decreased urinary output.

Correct Answer is B

Explanation

A bruit is a sound that can be heard with a stethoscope when blood flows through a narrowed or damaged artery. An abdominal bruit may indicate an abdominal aortic aneurysm (AAA), which is a bulge or swelling in the main blood vessel that runs from the heart down through the chest and tummy.

Shortness of breath is a common symptom of many conditions, but it is not specific to AAA. It can be caused by heart or lung problems, anemia, anxiety, lack of exercise, obesity, and many other factors. Shortness of breath may occur with a ruptured AAA, but it is not a reliable sign of an intact AAA.

Ripping abdominal pain is a severe and sudden pain that may indicate a ruptured AAA, which is a life-threatening situation that requires immediate medical attention. However, an intact AAA usually does not cause any pain or discomfort. Therefore, ripping abdominal pain is not a good indicator of an AAA diagnosis.

Decreased urinary output is a sign of reduced kidney function, which can have many causes such as dehydration, kidney failure, urinary tract obstruction, or medication side effects. Decreased urinary output is not directly related to AAA, although it may occur as a complication of a ruptured AAA or surgery to repair an AAA.

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A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the ﬁrst postoperative day?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with a heart rate of 124 bpm. What clinical ﬁnding(s) should the nurse assess as causes of tachycardia? Select all that apply.

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

Explanation

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Correct Answer is B

Explanation

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