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?

Temperature of 37.9° C (100.2° F)

Urine output 150 mL over 4 hr

Bruising around the incisional site

Pallor in the affected extremity

Answer and Explanation

The Correct Answer is D

A) Temperature of 37.9° C (100.2° F): A slight elevation in temperature can be common after surgery and may not indicate a serious issue. It should be monitored, but it is not immediately concerning.

B) Urine output 150 mL over 4 hr: While urine output is an important indicator of kidney function and overall perfusion, this output may still be acceptable depending on the client's overall fluid status and other factors. It does not necessarily require immediate reporting unless there are other concerning symptoms.

C) Bruising around the incisional site: Some bruising can be expected after surgery, particularly with arterial procedures. It should be monitored, but unless there are signs of excessive bleeding or hematoma formation, it is not typically an urgent concern.

D) Pallor in the affected extremity: This finding is critical and should be reported immediately. Pallor could indicate compromised blood flow to the extremity, which could be a sign of complications such as graft occlusion or inadequate perfusion. Prompt intervention may be necessary to prevent serious complications or tissue loss.

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Correct Answer is C

Explanation

A) Blistering at the site: Blistering is typically associated with partial-thickness burns rather than full-thickness burns. Full-thickness burns destroy both the epidermis and dermis, which usually do not present with blisters.
B) Epithelialization at the site: Epithelialization is a healing process that occurs after the burn site begins to heal. Since this client has sustained major full-thickness burns only 12 hours ago, epithelialization is not expected at this early stage.

C) Edema at the site: Edema is expected in the early stages following a major burn injury due to the inflammatory response and fluid shift that occurs. This finding aligns with the body's response to trauma and is common within the first 24 hours after a burn.

D) Severe pain at the site: Full-thickness burns typically have less pain at the site compared to partial-thickness burns because the nerve endings in the skin are destroyed. While there may be pain in surrounding areas or in partial-thickness areas, the full-thickness burn itself is often painless.

A. A client who has diabetes mellitus and is presenting with acute ketoacidosis B. A client who has a compound fracture of the right femur C. A client who reports having fever, right sweats, and cough for 2 days D. An older adult client who was admitted with aspiration pneumonia

Correct Answer is C

Explanation

A) A client who has diabetes mellitus and is presenting with acute ketoacidosis: While this client requires careful monitoring and may need a private room if they are at risk for complications, they generally do not require isolation from other clients.

B) A client who has a compound fracture of the right femur: This client does not require a private room. Although they may need specific positioning and care, there are typically no infectious or isolation concerns.

C) A client who reports having fever, right sweats, and cough for 2 days: This client requires a private room due to the possibility of an infectious condition, such as pneumonia or tuberculosis. Symptoms like fever and cough, along with sweating, raise concerns about contagious diseases, making isolation necessary to protect other clients.

D) An older adult client who was admitted with aspiration pneumonia: While this client may need close monitoring, they do not automatically require a private room unless there are additional infection control concerns or if they are particularly contagious.

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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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