A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?
The client's foot feels cooler than in the previous assessment.
The client's pedal pulse in the right foot is not palpable.
The client's capillary refill time is 5 seconds in the toes.
The client reports a pain level of 8 on a scale from 0 to 10.
The Correct Answer is B
The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood flow to the limb.
The other options are also concerning and should be reported to the healthcare provider.
a) A cooler foot may indicate decreased blood flow to the limb.
c) A capillary refill time of 5 seconds may also indicate decreased blood flow.
d) A pain level of 8 on a scale from 0 to 10 should also be reported and addressed.
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Related Questions
Correct Answer is D
Explanation
A client with heart failure should limit their sodium intake. Bottled salad dressings can be high in sodium, so replacing them with homemade vinegar and oil dressing can help reduce sodium intake.
The other options are not recommended for a client with heart failure who needs to limit their sodium intake.
a) Prepared frozen dinners are often high in sodium.
b) Adding salt when preparing a meal would increase sodium intake.
c) Imitation crab and lobster products (option can also be high in sodium.
Correct Answer is A
Explanation
The initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for a 2-month-old infant. The DTaP vaccine is typically administered as a series of doses starting in infancy to provide protection against diphtheria, tetanus, and pertussis (whooping cough).
The recommended schedule for the DTaP vaccine includes a series of doses at 2, 4, and 6 months of age, with additional booster doses given later in childhood. Therefore, the first dose of DTaP is given to infants at 2 months of age.
The other options are incorrect because:
b) A 4-month-old infant: By 4 months of age, the second dose of the DTaP vaccine should be administered, not the initial dose.
c) A 6-month-old infant: By 6 months of age, the third dose of the DTaP vaccine should be administered, not the initial dose.
d) A 15-month-old toddler: By 15 months of age, the toddler would have already received multiple doses of the DTaP vaccine as part of the recommended series. The initial dose is typically given earlier, at 2 months of age.
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