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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A client statement that indicates an understanding of discharge teaching for type 1 diabetes mellitus is "I will dispose of insulin needles in a puncture-proof container." This is the correct way to dispose of insulin needles to prevent accidental needle sticks.
The other options are not correct.
b) Opened insulin vials do not need to be stored in the refrigerator, but should be kept at room temperature.
c) Insulin vials should not be shakenas this can cause the insulin to break down.
d) Regular insulin should appear clear, not cloudy.
Correct Answer is B
Explanation
b. A decreased level of consciousness and vomiting
Explanation:
When receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. This combination of symptoms suggests a potentially serious condition that requires immediate atention and assessment. It could indicate a neurological or gastrointestinal issue, and further evaluation is necessary to determine the underlying cause and provide appropriate interventions.
Explanation for the other options:
a. Cellulitis accompanied by a low-grade fever:
While cellulitis and a low-grade fever require atention, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should prioritize assessing the client with altered consciousness and vomiting due to the potential for more urgent interventions.
c. A pain rating of 7 on a scale from 0 to 10 after receiving analgesia 30 min ago:
Although the client's pain rating of 7 indicates ongoing pain, it is not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first address the client with altered consciousness to determine the cause and provide appropriate interventions before assessing and managing pain in other clients.
d. Type 2 diabetes mellitus and a blood glucose level of 160 mg/dL:
While elevated blood glucose levels in a client with type 2 diabetes require atention and management, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first assess the client with altered consciousness to identify the cause and provide prompt interventions.
In summary, when receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. These symptoms indicate a potentially serious condition requiring immediate assessment and intervention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
