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.

Answer and Explanation

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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Correct Answer is C

No explanation

A. The client's most recent blood pressure reading was 110/60 mm Hg. B. The client's morning laboratory results included a potassium level of 4.9 mg/dL. C. The client has +2 pitting edema in the lower extremities. D. The client's partner assisted them with their meal tray.

Correct Answer is D

Explanation

The client's partner assisting them with their meal tray (option d) is not as important as the other information and may not need to be included in the change-of-shift report.

A nurse providing change-of-shift report for a client who has heart failure should include all of the above information in the report.

The client's most recent blood pressure reading,morning laboratory results, and presence of pitting edema in the lower extremities are all important pieces of information that the incoming nurse should be aware of.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a maternal newborn unit is assisting with the preparation of an in-service presentation about infection control. Which of the following information should the nurse recommend to include?

Correct Answer is C

A nurse is providing change-of-shift report for a client who has heart failure. Which of the following information should the nurse notinclude in the report?

Correct Answer is D

Explanation

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