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)

Answer and Explanation

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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Correct Answer is A

Explanation

A Pain typically occurs when the stomach is empty (1-3 hours after eating), often during the night and early morning. This pattern occurs because the presence of food helps to buffer gastric acid, whereas an empty stomach allows acid to directly contact the ulcerated area, leading to pain.

B. Pain in the right lower quadrant is not typically associated with peptic ulcer disease. Pain in PUD is usually located in the epigastric region (upper abdomen), although it can radiate to the back or other areas depending on the location and severity of the ulcer.

C. Constipation is not a typical finding in peptic ulcer disease. PUD is primarily associated with gastrointestinal symptoms related to acid-peptic imbalance, such as abdominal pain, bloating, nausea, and sometimes vomiting. Bowel habits are generally not directly affected by PUD.

D. In peptic ulcer disease, pain is usually relieved by eating or taking antacids. This is because food intake neutralizes gastric acid and provides a temporary protective coating over the ulcer, reducing irritation and pain.

A. Kussmaul respirations B. Increased urine output C. Cool, clammy skin D. Acetone breath

Correct Answer is C

Explanation

C. Cool, clammy skin is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body's sympathetic nervous system is activated, causing sweating and cool, clammy skin as a response to the stress of low blood sugar.

A Kussmaul respirations are deep, rapid, and labored breathing patterns that occur in response to diabetic ketoacidosis (DKA), a complication of hyperglycemia rather than hypoglycemia. In hypoglycemia, the body typically responds with normal or shallow respirations.

B Increased urine output (polyuria) is more commonly associated with hyperglycemia, where the kidneys try to excrete excess glucose through urine. Hypoglycemia typically does not cause increased urine output.

D. Acetone breath, which has a fruity odor, is associated with diabetic ketoacidosis (DKA), a condition caused by severe hyperglycemia and metabolic acidosis. It is not a typical finding in hypoglycemia.

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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

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