A patient recovering from aorto-femoral bypass surgery has developed edema, severe pain, paresthesia, and tightness of the operative limb.
The nurse recognizes that what post-operative complication is most likely causing the patient’s symptoms?
Wound infection.
Internal bleeding.
Graft rupture.
Compartment syndrome.
The Correct Answer is D
Choice D rationale
The symptoms described - edema, severe pain, paresthesia, and tightness of the operative limb
- are indicative of Compartment Syndrome. This is a serious condition that can occur after surgery, where increased pressure within one of the body’s compartments results in insufficient blood supply to the area. It requires immediate treatment to prevent permanent damage.
Choice A rationale
While wound infection is a possible post-operative complication, it would typically present with symptoms such as redness, increased pain at the wound site, purulent discharge, and possibly fever. The symptoms described do not specifically indicate a wound infection.
Choice B rationale
Internal bleeding could cause pain and swelling, but it would likely also present with signs of shock, such as low blood pressure, increased heart rate, and altered mental status. The symptoms provided do not clearly indicate internal bleeding.
Choice C rationale
Graft rupture is a serious complication that could potentially cause severe pain and swelling. However, it would also likely cause significant hemodynamic instability, including hypotension and tachycardia. The symptoms described are more indicative of Compartment Syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Soaking feet once daily in warm water is not recommended for diabetic patients. This is because prolonged soaking can lead to skin breakdown and increase the risk of foot ulcers and infections.
Choice B rationale
Utilizing a mirror to examine the soles of the feet is a recommended practice for diabetic patients. This allows them to check for any cuts, sores, blisters, or changes in the skin that they may not be able to see otherwise. Early detection of these issues can prevent serious complications such as infections and ulcers.
Choice C rationale
Cutting nails in a curved direction is not advised for diabetic patients. This can lead to ingrown toenails, which can cause sores and infections. It’s recommended to cut the nails straight across to avoid this.
Choice D rationale
Using a commercial medicine to remove a corn is not recommended for diabetic patients. These products can damage the skin and increase the risk of ulcers and infections. Any issues with corns or calluses should be addressed by a healthcare professional.
Correct Answer is A
Explanation
Choice A rationale
Fluid Volume Excess (FVE), or hypervolemia, refers to an isotonic expansion of the ECF due to an increase in total body sodium content and an increase in total body water. This fluid overload usually occurs from compromised regulatory mechanisms for sodium and water as seen commonly in heart failure (CHF), kidney failure, and liver failure. The key signs of hypervolemia include weight gain and swelling. One of the defining characteristics of FVE is an increase in urine specific gravity. Therefore, a urine specific gravity of 1.012 can validate the problem of Fluid Volume Excess for a patient.
Choice B rationale
+4 Pedal pulses indicate a very bounding and strong pulse, which is not directly related to Fluid Volume Excess. While it might be observed in some cases due to increased blood volume and pressure, it is not a specific or primary indicator of this condition.
Choice C rationale
A respiratory rate of 20/minute is within the normal range for an adult (12-20 breaths per minute) and does not specifically indicate Fluid Volume Excess. While respiratory changes can occur with severe or prolonged Fluid Volume Excess, a normal respiratory rate does not validate this diagnosis.
Choice D rationale
A potassium level of 3.8 mEq/L is within the normal range (3.5-5.0 mEq/L) and does not specifically indicate Fluid Volume Excess. While electrolyte imbalances can occur with Fluid Volume Excess, a normal potassium level does not validate this diagnosis.
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