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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) NG tube:
An NG (nasogastric) tube is used for feeding or draining stomach contents and is not specifically required for the management of seizures. It does not play a role in the immediate care of a client having a seizure and is therefore not necessary to have readily available in the client's room.

B) Wrist restraints:
Wrist restraints are generally not recommended for clients experiencing seizures. Using restraints can increase the risk of injury during a seizure and may not prevent the client from harming themselves. Safety measures should focus on protecting the client from harm rather than restraining them.

C) Oral airway:
An oral airway can be useful in maintaining a clear airway during or immediately after a seizure, especially if there is a risk of airway obstruction due to the client's condition or if the client is at risk of respiratory compromise. It is an appropriate piece of equipment to have available to ensure the client's airway remains patent.

D) Tongue blade:
A tongue blade should never be used to force open a client’s mouth during a seizure, as this can lead to injury to both the client and the caregiver. The primary goal during a seizure is to ensure the client’s safety by preventing injury, not by using potentially harmful interventions.

A. Temperature 36.3° C (97.3° F) B. Respiratory rate 10/min C. Blood pressure 138/76 mm Hg D. Heart rate 48/min

Correct Answer is D

Explanation

A) Temperature 36.3°C (97.3°F):
A temperature of 36.3°C is within the normal range and is not indicative of an adverse effect related to metoprolol. This temperature does not suggest an abnormal response or side effect of the medication.

B) Respiratory rate 10/min:
A respiratory rate of 10 breaths per minute is considered low and could indicate respiratory depression. However, while bradycardia is more closely related to metoprolol, this finding still warrants monitoring but is not the primary adverse effect to focus on for this medication.

C) Blood pressure 138/76 mm Hg:
A blood pressure of 138/76 mm Hg is within the acceptable range and does not suggest an adverse effect from metoprolol. Metoprolol is used to lower blood pressure, so if anything, it would be more likely to cause a lower reading if it were to affect blood pressure adversely.

D) Heart rate 48/min:
A heart rate of 48 beats per minute is indicative of bradycardia, which is a known adverse effect of metoprolol. Metoprolol, as a beta-blocker, can decrease heart rate, and a rate this low may require adjustment of the medication or further evaluation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

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