A nurse is caring for a client post-endarterectomy for carotid artery stenosis. What is the priority nursing intervention during the immediate postoperative period?
Monitoring for signs of stroke
Assessing the surgical incision for bleeding
Administering pain medications
Encouraging coughing and deep breathing
The Correct Answer is A
A) Correct - Monitoring for signs of stroke is the priority during the immediate postoperative period for a client who underwent carotid artery endarterectomy. The procedure involves removing plaque buildup from the carotid artery, which can potentially dislodge and cause a stroke.
B) Incorrect - Assessing the surgical incision for bleeding is important, but it is not the priority when compared to monitoring for signs of stroke after a carotid endarterectomy.
C) Incorrect - Administering pain medications is essential for the client's comfort, but it is not the priority during the immediate postoperative period when there is a higher risk of stroke.
D) Incorrect - Encouraging coughing and deep breathing is a standard postoperative nursing intervention, but it is not the priority in this situation. The focus should be on monitoring for stroke symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect - Hypoglycemia is not a common complication of femoral artery catheterization. It is not directly related to the procedure or the femoral artery itself.
B) Incorrect - Hypothermia is not a typical complication of femoral artery catheterization. The procedure is typically performed under controlled environmental conditions.
C) Correct - Bleeding and hematoma at the insertion site are common complications of femoral artery catheterization. The nurse should closely monitor the insertion site for any signs of bleeding or swelling.
D) Incorrect - While elevated blood pressure can be a concern after some procedures, it is not a specific complication of femoral artery catheterization. The primary focus after the procedure is on monitoring the insertion site.
Correct Answer is B
Explanation
A) Incorrect - Assessing pain level at the insertion site is important but not the priority assessment when evaluating the immediate complications of femoral artery cannulation.
B) Correct - Assessing peripheral pulses distal to the insertion site is the priority when evaluating the adequacy of blood flow after femoral artery cannulation. Diminished or absent pulses may indicate vascular compromise.
C) Incorrect - The client's ability to ambulate independently is a relevant assessment but not the priority when immediately assessing the complications of femoral artery cannulation.
D) Incorrect - Capillary refill of the fingers is important but is not the priority assessment in the immediate post-procedure period following femoral artery cannulation.
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