The nurse assesses a client who just returned to the recovery area after undergoing a balloon angioplasty to improve circulation to the left leg. What assessment finding is the most concerning?
Client reports a pain level of 3/10.
Left groin has minimal bruising.
Left leg with weakened pedal pulse and is cool to the touch.
Blood pressure 154/78 mmHg.
The Correct Answer is C
A. A mild pain level of 3/10 is common after angioplasty and is not immediately concerning.
B. Minimal bruising at the groin is expected after this procedure and is not alarming.
C. A weakened pedal pulse and a cool leg could indicate compromised circulation, which is a serious concern post-angioplasty. Immediate assessment is needed to check for possible complications such as re-occlusion.
D. A blood pressure of 154/78 mmHg is somewhat elevated but not alarming.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sucking on small quantities of ice chips is not appropriate in this case as it may worsen the airway obstruction or cause further irritation.
B. Applying oxygen and continuously monitoring the client's pulse oximetry will help ensure that the client's oxygen saturation remains adequate and that they do not experience respiratory distress or hypoxemia due to inhalation injury. Early intervention is crucial to prevent worsening of respiratory status.
C. Humidified room air can help in cases of airway irritation, but the priority is to ensure oxygenation and avoid hypoxia.
D. Antitussive medications may be indicated later, but airway management and oxygenation take precedence.
Correct Answer is B
Explanation
A. A stable client with chronic angina is not in immediate danger, and the scheduled dose of nifedipine is not an urgent priority.
B. The client with unstable angina who has just undergone a heart catheterization with balloon angioplasty requires immediate assessment for complications such as bleeding, clot formation, or re-occlusion of the artery.
C. The 65-year-old post-MI client is stable, and while their anxiety is important to address, it is not an immediate concern compared to other clients.
D. The client post-coronary artery bypass with a potassium level of 4.2 mEq/L is stable and does not require urgent intervention.
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