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

Answer and Explanation

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.

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Correct Answer is ["A","B"]

Explanation

Choice A reason: Keeping the radiation area clean with mild soap and water helps maintain hygiene and prevent infection. It is important to use gentle, non-irritating cleansers to avoid aggravating the skin that is already sensitive due to radiation.

Choice B reason: Avoiding exposure of the radiation site to extreme temperatures is crucial. Heat can increase irritation, and cold can cause additional discomfort. Protecting the area from extreme temperatures helps in reducing skin reactions and promoting healing.

Choice C reason: Wearing tight clothing is not recommended for patients undergoing radiation therapy. Tight clothing can cause friction and irritation on the already sensitive radiation site, potentially worsening skin reactions.

Choice D reason: Applying fragrant lotions to the radiation area is not advised. Fragrances and certain chemicals in lotions can irritate the skin and lead to adverse reactions. It is better to use unscented, gentle moisturizers if needed.

A. Oxygen mask B. Nasogastric tube C. Urinary catheter D. Suction set-up E. Tongue blade F. Side rail pads

Correct Answer is ["A","D","F"]

Explanation

Choice A reason: An oxygen mask is essential for providing supplemental oxygen to the patient, especially if they experience respiratory distress or decreased oxygen saturation following a seizure. Ensuring adequate oxygenation is a priority in post-seizure care.

Choice B reason: A nasogastric tube may be used in specific situations for feeding or medication administration, but it is not routinely necessary for all patients treated for status epilepticus.

Choice C reason: A urinary catheter is used for managing urinary output, particularly in patients with retention or incontinence issues, but it is not immediately required for all patients post-status epilepticus.

Choice D reason: Suction set-up is necessary for maintaining the patient's airway and preventing aspiration, particularly if the patient has excessive secretions or vomits after a seizure. Suction equipment allows the nurse to quickly clear the airway and ensure the patient can breathe effectively.

Choice E reason: Tongue blades are not recommended for seizure management as they can cause injury. Historically, there was a misconception about using tongue blades to prevent tongue biting during seizures, but this practice is now discouraged due to the risk of oral injury.

Choice F reason: Side rail pads are important for protecting the patient from injury during potential future seizures. Padded side rails help prevent trauma from hitting the bed rails during convulsions and provide a safer environment for the patient.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B"]

Explanation

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply)

Correct Answer is ["A","D","F"]

Explanation

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