The nurse provides postoperative care to a patient who underwent peripheral artery bypass surgery. Thirty minutes after the initial assessment, the nurse reassesses the patient and detects a change in the Doppler sound over a pulse. Which action should the nurse take?
Contact the health care provider
Recheck the pulse in another 30 minutes
Measure the ankle-brachial index
Administer an oral anticoagulant
The Correct Answer is A
Choice A reason: Contacting the health care provider is the most appropriate action because a change in the Doppler sound may indicate a potential complication, such as graft occlusion or compromised blood flow. Immediate assessment and intervention by the health care provider are essential to prevent further complications and ensure the patient's safety.
Choice B reason: Rechecking the pulse in another 30 minutes is not advisable in this situation because it could delay necessary medical intervention. Prompt communication with the health care provider is crucial to address the underlying issue and provide timely care.
Choice C reason: Measuring the ankle-brachial index can provide valuable information about blood flow in the lower extremities, but it is not the immediate priority when a significant change in the Doppler sound is detected. Contacting the health care provider for further assessment and instructions takes precedence.
Choice D reason: Administering an oral anticoagulant is not an appropriate action without the direct instruction from a health care provider. The nurse must first report the change in the Doppler sound to the provider and follow their specific orders regarding medication and treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","C"]
Explanation
Choice A reason: Shivering can be a response to various conditions, including cold temperatures or fever, but it is not a direct indicator to discontinue suctioning. While it may be concerning, it does not specifically suggest a problem caused by the suctioning procedure.
Choice B reason: Decreased SpO₂ (oxygen saturation) is a critical sign that the patient is not getting enough oxygen. This condition requires immediate attention, and suctioning should be stopped to assess and address the cause of the hypoxia. Continuing to suction can exacerbate respiratory distress and further lower oxygen levels.
Choice C reason: Absence of coughing is a sign that the patient's airway may be compromised or that the suctioning is too aggressive, potentially leading to further complications. Coughing is a protective reflex that helps clear the airway, and its absence indicates that the airway is not adequately protected, warranting cessation of suctioning.
Choice D reason: Development of dysrhythmias (irregular heartbeats) during suctioning is a serious concern. Dysrhythmias can indicate that the patient is experiencing significant physiological stress or that the vagus nerve is being stimulated, which can impact heart function. Immediate discontinuation of suctioning is necessary to prevent cardiac complications and to stabilize the patient's condition.
Choice E reason: Increased blood pressure, while indicative of stress or pain, is not an immediate indicator to stop suctioning. It should be monitored and addressed, but it does not pose the same immediate risk as decreased oxygen saturation or dysrhythmias.
Correct Answer is D
Explanation
Choice A reason: Cantaloupe and cottage cheese are not particularly high in iron. While cantaloupe provides vitamin C, which can enhance iron absorption, the overall iron content of this meal is low, making it less effective for treating iron-deficiency anemia.
Choice B reason: Cornmeal muffin and orange juice offer some nutrients, including vitamin C from orange juice, which helps with iron absorption. However, cornmeal muffins do not provide significant iron content, making this choice suboptimal for iron-deficiency anemia.
Choice C reason: Strawberry and banana fruit plate provides vitamins and minerals, including vitamin C from strawberries, but it lacks substantial iron content. This choice is not adequate for addressing iron-deficiency anemia.
Choice D reason: Omelet and whole wheat toast are excellent choices for increasing dietary iron intake. Eggs in the omelet provide heme iron, which is easily absorbed by the body, and whole wheat toast contains non-heme iron. Combined, they offer a balanced and effective meal for managing iron-deficiency anemia.
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