A nurse is assessing a client who is 4 hr. postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?
Pallor in the affected extremity
Urine output 150 ml over 4 hr
Temperature of 37.9° C (100.2°F)
Bruising around the incisional site
The Correct Answer is A
A) Pallor in the affected extremity:
Pallor in the affected extremity is a critical finding that indicates potential compromised blood flow to the area, which can be a sign of graft failure, arterial occlusion, or inadequate perfusion. This requires immediate evaluation by the healthcare provider to prevent serious complications such as limb ischemia or loss.
B) Urine output 150 ml over 4 hr:
While low urine output can be concerning, a urine output of 150 ml over 4 hours may not be immediately alarming unless there are other symptoms of acute kidney injury or dehydration. This would need to be monitored, but it is less urgent compared to signs of compromised blood flow.
C) Temperature of 37.9° C (100.2°F):
A temperature of 37.9°C (100.2°F) is mildly elevated and may indicate a low-grade fever, which can occur postoperatively due to various reasons, including inflammatory responses. It is not as immediately critical as signs of impaired perfusion.
D) Bruising around the incisional site:
Bruising around the incisional site is a common postoperative finding and typically not immediately concerning unless it is associated with significant bleeding or signs of hematoma formation. It should be monitored but does not generally require immediate reporting unless accompanied by other alarming symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Restlessness:
Restlessness is an early sign of increased intracranial pressure (ICP). It results from the brain's initial response to the pressure changes, which can cause alterations in mental status, such as confusion, agitation, or anxiety. Identifying restlessness early allows for timely intervention to prevent further complications.
B) Papilledema:
Papilledema is the swelling of the optic disc due to increased ICP, but it typically develops later in the progression of the condition. It is often observed on a fundoscopic examination and indicates more prolonged or severe intracranial hypertension.
C) Projectile vomiting:
Projectile vomiting can occur with increased ICP but is usually a later sign. It is associated with pressure on the brainstem and is often accompanied by other severe symptoms, such as headache and changes in consciousness.
D) Decorticate posturing:
Decorticate posturing is a late sign of increased ICP and indicates significant brain injury or herniation. It involves abnormal flexion of the arms and extension of the legs, reflecting severe damage to the corticospinal tract.
Correct Answer is C
Explanation
A. "Wear your dentures only during meals."
Wearing dentures only during meals can help reduce irritation to the mucous membranes, but it may not address the overall management of mucositis. It’s important to focus on maintaining oral hygiene and minimizing trauma to sensitive tissues.
B. "Rinse your mouth with hydrogen peroxide."
Hydrogen peroxide can be irritating to oral tissues and may exacerbate mucositis. It’s typically better to use a saline or bicarbonate mouthwash, which is gentler and helps soothe the mouth without causing further irritation.
C. "Floss your teeth gently following each meal."
Gently flossing helps remove food particles and plaque, reducing the risk of infection. It is important to perform this carefully to avoid damaging the already sensitive and inflamed mucosa, promoting oral health while managing mucositis.
D. "Brush your teeth for 60 seconds twice daily."
Brushing is essential, but it should be done gently with a soft-bristled brush. Brushing for a specific duration is less important than ensuring it is done carefully to prevent further irritation or injury to the mouth.
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