An older adult client who had an aortic aneurysm repair today is transferred from intensive care to a medical-surgical unit on the first postoperative day. While assessing the client, the nurse notes edema of both lower extremities and is unable to palpate the pedal pulses. Which intervention should the nurse implement?
Use a bed cradle to support linen above the legs.
Use a Doppler ultrasound to reassess the pulses.
Elevate the extremities above the level of the heart.
Wrap the lower extremities with warm blankets.
The Correct Answer is B
Rationale:
A. Use a bed cradle to support linen above the legs: A bed cradle helps prevent pressure from linens on the legs, but it does not address absent or difficult-to-palpate pulses. This intervention is supportive but not diagnostic or priority-focused.
B. Use a Doppler ultrasound to reassess the pulses: When pedal pulses cannot be palpated, a Doppler allows accurate assessment of blood flow and perfusion. Prompt evaluation is essential to detect potential arterial compromise or postoperative complications, such as thrombosis or edema-related vascular obstruction.
C. Elevate the extremities above the level of the heart: Elevation reduces edema but may worsen arterial perfusion if pulses are already absent. Before positioning, confirming circulation with Doppler assessment ensures interventions do not exacerbate ischemia.
D. Wrap the lower extremities with warm blankets: Warming may improve comfort and circulation slightly, but it does not provide objective assessment of vascular status or address potential postoperative vascular compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Sluggish pupillary response: A delayed pupillary reaction may indicate increased intracranial pressure or neural pathway involvement but is not immediately life-threatening. It warrants monitoring and documentation rather than urgent intervention unless accompanied by other neurological changes.
B. Respiratory rate 6 breaths/minute: A severely decreased respiratory rate signals respiratory compromise from loss of diaphragmatic or intercostal muscle control, common with high cervical spine injuries. This finding indicates impending respiratory arrest and requires immediate airway and ventilatory support.
C. Average urinary output 20 mL/hour: Reduced urine output suggests decreased renal perfusion or possible neurogenic bladder, but it is not immediately life-threatening. It should be reported for evaluation but is secondary to managing respiratory failure risk.
D. Heart rate 140 beats/minute: Tachycardia may occur due to pain, anxiety, or autonomic disruption but does not pose the same acute risk as respiratory depression. It should be monitored and managed appropriately after ensuring adequate oxygenation and ventilation.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices
• Obstructed tracheostomy: The client presents with thick, green mucus and diminished breath sounds in the right lower lobe, suggesting mucus plugging within the tracheostomy tube that limits air movement. Obstruction commonly occurs in patients with inadequate humidification or ineffective suctioning, leading to impaired ventilation and secretion buildup.
• Traumatic iatrogenic pneumothorax: The right-sided diminished lung sounds and pleural effusion on imaging are consistent with complications often resulting from tracheostomy care or suctioning trauma. Iatrogenic pneumothorax occurs when airway instrumentation or pressure changes injure the pleura, allowing air into the pleural space and collapsing the lung.
Rationale for Incorrect Choices
• Primary spontaneous pneumothorax: This occurs without underlying lung disease, often in tall, thin young adults. It is inconsistent with this client’s medical history of cerebral palsy and chronic oxygen therapy.
• Displaced tracheostomy: A displaced tracheostomy would cause acute respiratory distress, abnormal tracheal sounds, or subcutaneous emphysema. None of these findings are present, and oxygenation appears stable at her baseline FiO₂.
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