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 A

Explanation

A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates severe respiratory distress or failure. In this situation, the client's oxygenation is compromised, and immediate intervention is needed to ensure an open and unobstructed airway. The nurse should prioritize ensuring the client has a patent airway by assessing for any airway obstruction and taking appropriate measures to clear the airway if necessary. This may involve techniques such as the head tilt-chin lift or jaw thrust maneuver.

While administering oxygen, checking the client's pulse rate, and placing a pulse oximeter on the client's finger are all important interventions in managing respiratory distress, the first and most critical step is to establish a patent airway. Without a clear airway, the client's oxygenation cannot be adequately addressed, and other interventions may be ineffective. Once the airway is secured, the nurse can proceed with providing oxygen, assessing the client's vital signs, and monitoring oxygen saturation using a pulse oximeter.

A. Instruct the client to report the theft to the police B. Report the possible abuse to adult protective services. C. Ask the client if there is another family member they can call for financial help. D. Restrict visitation for the client's family until discharge.

Correct Answer is B

Explanation

The nurse should report the possible abuse to adult protective services if an older adult client states that their child took all their money. This is an important nursing intervention to ensure the safety and well-being of the client.

a) Instructing the client to report the theft to the police may be appropriate, but it is not the first action the nurse should take. The nurse has a legal and ethical obligation to report suspected abuse to the appropriate authorities.

c) Asking the client if there is another family member they can call for financial help may be appropriate, but it does not address the issue of possible abuse.

d) Restricting visitation for the client's family until discharge is not appropriate and may violate the client's rights.

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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 is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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