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?
Bruising around the incisional site
Pallor in the affected extremity
Urine output 150 mL over 4 hr
Temperature of 37.9° C (100.2° F)
The Correct Answer is B
B. Pallor suggests potential compromised arterial blood flow or perfusion issues, which require immediate assessment and intervention to ensure the viability of the revascularized artery and the extremity.
A Bruising can be a common finding after surgery, especially involving vascular procedures. It is typically due to minor bleeding into the tissues around the surgical site.
C. Postoperative oliguria (low urine output) can indicate inadequate renal perfusion, which may result from hypovolemia or impaired cardiac output. 150ml in 4 hours does not immediately indicate a need for urgent intervention
D. A mild increase in temperature is common in the immediate postoperative period and can be due to the body's normal response to surgical stress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. This sequence is important because regular insulin should not be contaminated with NPH insulin, and drawing up regular insulin first helps ensure accurate dosing and prevents mixing of the two insulins prematurely.
A Insulin injections are typically administered subcutaneously, which usually requires a 90-degree angle (perpendicular) for needle insertion, especially if the person has adequate subcutaneous tissue.
B. Prefilled insulin syringes should be stored with the needle pointing upward to prevent insulin leakage or air bubbles from affecting the accuracy of the dose.
C NPH (Neutral Protamine Hagedorn) insulin is a suspension and should not be vigorously shaken. Shaking could cause frothing or denaturation of the insulin, affecting its efficacy and consistency.
Correct Answer is B
Explanation
A Clearing the area is essential to prevent injury during a seizure. The client may move or thrash around, and any objects nearby (e.g., furniture, medical equipment, or sharp objects) can potentially cause harm. However, this can be done after lowering teh client.
B. This action is crucial to protect the client from injury during the seizure. It provides a safe environment for the client to have the seizure without risk of falling or hitting their head on objects.
C. Assessing vital signs can wait until after the seizure has ended and the client's immediate safety has been ensured. During a seizure, the nurse should focus on managing the seizure and preventing complications.
D. This action is important for comfort and safety but is secondary to ensuring a safe environment and managing the seizure itself.
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