The nurse is caring for a client who is two days post-aortic-iliac bypass surgery. Which assessment finding should be reported to the surgeon immediately?
Blood pressure of 98/60.
Urine output of 40 mL/hour.
Pain rated as 5 on a 0-10 scale.
Absence of popliteal pulse.
The Correct Answer is D
Choice A Reason:
A blood pressure of 98/60, while on the lower side, is not necessarily alarming post-surgery unless the patient shows symptoms of hypotension or if there is a significant drop from the patient's baseline blood pressure. It is important to monitor trends in blood pressure readings rather than a single isolated measurement.
Choice B Reason:
A urine output of 40 mL/hour can be considered within normal limits post-surgery, as the expected urine output is at least 0.5 mL/kg/hr. However, it should be monitored closely to ensure that it does not decrease further, which could indicate renal complications.
Choice C Reason:
Pain rated as 5 on a 0-10 scale indicates moderate pain, which is expected post-surgery. Pain management should be continued as prescribed, and the patient should be reassessed regularly to ensure that the pain does not escalate.
Choice D Reason:
The absence of a popliteal pulse is a critical finding that must be reported immediately. The popliteal artery provides blood flow to the lower leg, and its absence could indicate graft occlusion or other serious circulatory issues, which could lead to limb-threatening complications if not addressed promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason
A creatinine level of 0.8 mg/dL falls within the normal range for adults, which is typically 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. This indicates normal kidney function and is not a cause for immediate intervention post-operatively.
Choice B Reason
A potassium level of 4.2 mEq/L is within the normal range, which is generally between 3.6 and 5.2 mEq/L. This level indicates a stable electrolyte balance and is not a cause for immediate concern following shoulder replacement surgery.
Choice C Reason
A white blood cell (WBC) count of 9,000 mm³ is within the normal range, which typically spans from 4,500 to 11,000 WBCs per mm³. This suggests there is no active infection or inflammation that requires immediate intervention.
Choice D Reason
A hemoglobin level of 7.1 g/dL is considered low, as the normal range for adult males is generally 13.8 to 17.2 g/dL and for adult females is 12.1 to 15.1 g/dL. Low hemoglobin can indicate anemia, which may be due to blood loss during surgery or other underlying conditions. This requires immediate intervention to address potential oxygenation issues and determine the cause of the anemia.
Correct Answer is D
Explanation
Choice A reason:
Ulnar deviation, which is the angling of the fingers towards the little finger side of the hand, is more commonly associated with rheumatoid arthritis, not osteoarthritis. Osteoarthritis typically affects the joint's cartilage, leading to pain and stiffness, rather than causing the fingers to deviate.
Choice B reason:
Symmetric joint involvement is also more characteristic of rheumatoid arthritis. Osteoarthritis usually affects joints asymmetrically, meaning it's more likely to affect one side of the body or one particular joint at a time.
Choice C reason:
Weight loss is not a direct manifestation of osteoarthritis. In fact, being overweight is a risk factor for developing osteoarthritis due to the increased stress on weight-bearing joints. However, weight management through diet and exercise can be part of the treatment plan for osteoarthritis to alleviate symptoms and improve joint function.
Choice D reason:
Joint stiffness and limited range of motion are hallmark manifestations of osteoarthritis. These symptoms result from the breakdown of cartilage within the joints, which leads to pain and difficulty moving the affected joint. Stiffness is often most noticeable upon waking or after periods of inactivity, and the range of motion may decrease as the condition progresses.
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