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?

Urine output 150 mL over 4 hr

Pallor in the affected extremity

Bruising around the incisional site

Temperature of 37.9° C (100.2° F)

Answer and Explanation

The Correct Answer is B

A. Urine output of 150 mL over 4 hr is within normal range and does not indicate an immediate problem.

B. Pallor in the affected extremity could indicate compromised blood flow, which is a serious concern following revascularization and requires immediate attention.

C. Bruising around the incisional site can be expected and does not necessarily indicate a complication.

D. A temperature of 37.9° C (100.2° F) is slightly elevated but not uncommon postoperatively and not as urgent as pallor in the extremity.

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Correct Answer is A

Explanation

A. Increasing the elevation of the affected extremity helps to relieve pressure and maintain proper alignment of the fracture. This action ensures that the traction remains effective and that the weights are properly suspended.

B. Removing weights can compromise the effectiveness of the traction and should only be done under specific orders from a healthcare provider.

C. Tying knots in the ropes can alter the alignment and effectiveness of the traction. Proper adjustment should be made by healthcare professionals according to protocol.

D. Pulling the client up in bed does not address the issue of the weights resting on the floor and may cause further complications.

A. Tap the client's facial nerve and note any facial twitching. B. Run a tongue blade on the outside of the client's sole and note any flaring of the toes. C. Gently elevate the client's head and note any nuchal rigidity. D. Strike the client's patellar tendon with a percussion hammer and note any increase in response.

Correct Answer is C

Explanation

A. Facial nerve testing is not specific to bacterial meningitis and does not help in the diagnosis.

B. Running a tongue blade on the outside of the sole is not a relevant test for meningitis.

C. Elevating the head to assess for nuchal rigidity (stiff neck) is a classic sign of meningitis and helps in diagnosis.

D. Testing the patellar tendon reflexes is not specific to meningitis; other signs are more relevant for diagnosis.

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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?

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