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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Measuring abdominal girth can help monitor the aneurysm.

B. Auscultation is safe and may reveal bruits associated with aneurysms.

C. Palpation of the abdominal midline area is dangerous and can risk rupturing the aneurysm, requiring further education.

D. Observation is non-invasive and safe.

A. Base deficit (HCO3): Acidosis B. Acid excess (CO2): Acidosis C. Base excess (HCO3): Alkalosis D. Acid deficit (CO2): Alkalosis

Correct Answer is B

Explanation

A. Base deficit (HCO3): Acidosis: A base deficit indicates metabolic acidosis, but respiratory acidosis is more likely with the high rate of ventilation.

B. Acid excess (CO2): Acidosis: This is the correct answer. A high respiratory rate can lead to hyperventilation, decreasing CO2 levels and causing respiratory alkalosis, which may be a concern with an elevated rate.

C. Base excess (HCO3): Alkalosis: This would indicate metabolic alkalosis, but it is not as related to ventilator settings.

D. Acid deficit (CO2): Alkalosis: If the CO2 level is too low due to hyperventilation, this can lead to alkalosis, which the nurse is questioning here.

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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?

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Naxlex Comprehensive Predictor Exams

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