The nurse is caring for a patient after a popliteal bypass graft surgery. Which assessments will the nurse perform during the first postoperative day?

Perform doppler evaluation once daily

Assess for compartment syndrome every 2 hours

Assess pulse of affected extremity every 15 minutes until stable

Palpate the affected leg for pa every shift

Answer and Explanation

The Correct Answer is C

A. Perform doppler evaluation once daily: While Doppler evaluation is valuable for assessing blood flow and detecting vascular abnormalities, performing it only once daily may not provide adequate monitoring, especially during the critical early postoperative period. More frequent assessments are necessary to ensure optimal graft function and to promptly identify any complications.

B. Assess for compartment syndrome every 2 hours: While assessing for compartment syndrome is important, performing assessments every 2 hours may not be necessary unless specific risk factors or clinical indications are present. Continuous monitoring for signs and symptoms of compartment syndrome is essential, but the frequency of assessment should be based on the patient's condition and the surgeon's orders.

C. Assess pulse of affected extremity every 15 minutes until stable: After popliteal bypass graft surgery, assessing the pulse of the affected extremity every 15 minutes until stable is crucial. Frequent pulse checks help monitor graft patency and perfusion to detect early signs of graft failure or ischemia. This high-frequency assessment allows for prompt identification of vascular compromise and timely intervention to prevent graft thrombosis or occlusion. Once the pulse is stable and adequate perfusion is confirmed, the frequency of pulse checks can be adjusted according to the patient's condition and clinical guidelines.

D. Palpate the affected leg for pain every shift: Palpating the affected leg for pain every shift is an important component of postoperative assessment. However, relying solely on pain assessment once per shift may not provide timely detection of complications or changes in the patient's condition, especially during the immediate postoperative period when close monitoring is necessary. Frequent and ongoing assessment of pain, along with other vital signs and clinical indicators, is essential for comprehensive postoperative care.

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Correct Answer is C

Explanation

A. Continue to administer the metoprolol tartrate as ordered:
Metoprolol is a beta-blocker commonly used to treat hypertension, angina, and heart failure. One of its main effects is to decrease heart rate and blood pressure. In this scenario, the patient's vital signs reveal a low heart rate (48 bpm) and relatively low blood pressure (100/50 mmHg). Given that metoprolol can further reduce heart rate and blood pressure, it would be prudent for the nurse to withhold the medication until further assessment is conducted.

B. Ask the patient if her pulse is within the normal range:
While it's essential to assess the patient's understanding of her condition, asking if her pulse is within the normal range is not sufficient. The nurse should perform a more thorough assessment and consider the clinical significance of the vital signs obtained. In this case, a heart rate of 48 bpm is lower than the typical normal range for adults (60-100 bpm), indicating bradycardia, which may be symptomatic or concerning in the context of administering a beta-blocker like metoprolol.

C. Hold the medication and call the provider:
Given the patient's low heart rate (bradycardia) and relatively low blood pressure, holding the metoprolol tartrate and contacting the healthcare provider is the most appropriate action. Bradycardia and hypotension can be signs of excessive beta-blockade, especially with medications like metoprolol, which can further lower heart rate and blood pressure. The nurse should notify the provider promptly to discuss the patient's condition and determine the appropriate course of action.

D. Ask the patient to eat salty foods:
Encouraging the patient to eat salty foods would not address the underlying issue of bradycardia and hypotension. While increasing salt intake may help raise blood pressure in some cases, it is not a standard intervention for managing symptomatic bradycardia or low blood pressure caused by medication effects.

A. Administer post-exposure prophylaxis medication. B. Determine the HIV status of the patient. C. Advise exposed health care providers to use precautions. D. Undergo early reevaluation after exposure.

Correct Answer is C

Explanation

A. Administer post-exposure prophylaxis medication: Administering post-exposure prophylaxis (PEP) medication is an essential step in preventing HIV transmission after a needlestick injury. However, it is not the first action to be taken. Before administering PEP, immediate precautions should be implemented to minimize the risk of transmission.

B. Determine the HIV status of the patient: While knowing the HIV status of the patient is important for assessing the risk of transmission, it is not the first action to be taken after a needlestick injury. Obtaining the patient's HIV status may take time and may not be immediately available. Therefore, other precautionary measures should be implemented first.

C. Advise exposed health care providers to use precautions: This is the most immediate and appropriate action following a needlestick injury. Advising exposed healthcare providers to use precautions, such as wearing gloves and washing the affected area thoroughly, helps minimize the risk of HIV transmission immediately after the incident. It is essential to prioritize safety measures for the healthcare provider while waiting for further assessment and management steps.

D. Undergo early reevaluation after exposure: While early reevaluation after exposure is important, especially for assessing the need for additional medical interventions, it is not the first action to be taken. Immediate precautions to prevent transmission should be prioritized before further evaluation.

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The nurse is caring for a patient after a popliteal bypass graft surgery. Which assessments will the nurse perform during the first postoperative day?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse takes a patient's vital signs prior to giving metoprolol tartrate and obtains the following results: T 98 degrees F, P 48, R 16 bpm, BP 100/50 and a pulse oximeter of 98%. What action will the nurse take?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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