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.
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Related Questions
Correct Answer is C
Explanation
C. Monitoring urine output is crucial in the early postoperative period after a kidney transplant to assess kidney function and ensure adequate perfusion.
A Managing pain is important, but the administration of opioids should be carefully considered due to their potential to mask symptoms and side effects that could be critical in the postoperative period.
B. While electrolyte imbalances are important to monitor, hypokalemia specifically is not typically associated with acute rejection in the early postoperative period.
D. Blood pressure monitoring every 8 hours may not be sufficient in the immediate postoperative period, especially given the potential for fluid shifts and changes in hemodynamic status.
Correct Answer is D
Explanation
D. Naloxone competitively binds to opioid receptors, displacing opioids from these receptors and rapidly reversing their effects. It is the drug of choice for managing opioid-induced respiratory depression and is administered to restore adequate ventilation and prevent respiratory arrest.
A Diphenhydramine is an antihistamine with sedative properties. It is used primarily for allergic reactions and as a sleep aid. Diphenhydramine is not indicated for reversing respiratory depression caused by opioid overdose. It does not antagonize opioid receptors or reverse the effects of opioids.
B. Flumazenil is not effective in reversing respiratory depression caused by opioid overdose. It does not affect opioid receptors or reverse the respiratory depressant effects of opioids.
C. Calcium gluconate is a form of calcium used to treat hypocalcemia or to counteract the cardiac effects of hyperkalemia. It does not reverse opioid-induced respiratory depression. It is not indicated in this situation.
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