Upon assessment of a patient in the recovery room following knee arthroplasty, the nurse notes decreased pedal pulses.
What is the most appropriate initial action for the nurse to take?
Reassess circulation and compare to preoperative baselines.
Elevate the affected leg above the level of the heart.
Contact the surgeon immediately to report the findings.
Activate the emergency response team.
The Correct Answer is A
Choice A rationale
The initial nursing action must be assessment to determine the significance of the finding. Decreased pulses can be a sign of vascular compromise, but they must be compared to the preoperative baseline. Some patients have naturally faint pulses or peripheral vascular disease present before surgery. Normal capillary refill is typically < 3 seconds. By comparing current data to the baseline, the nurse can determine if this is a new, acute change or a pre-existing condition before escalating care.
Choice B rationale
Elevating the leg significantly above the heart level is contraindicated if arterial flow is already compromised. While slight elevation helps with venous return and reduces edema, extreme elevation can further decrease arterial perfusion pressure to the distal extremity. This could worsen ischemia if the decreased pulses are due to arterial occlusion or compartment syndrome. The nurse should keep the limb at a neutral level or slightly elevated until the circulatory status is fully clarified through assessment.
Choice C rationale
Contacting the surgeon is an appropriate action, but it is not the first action. The nurse must first gather all necessary assessment data, including skin temperature, color, sensation, and motor function, to provide a comprehensive SBAR report. Reporting a single finding without context or comparison to baseline data is inefficient. The nurse should verify the findings and check for other signs of neurovascular impairment, such as paresthesia or coolness, before notifying the surgical team of a potential complication.
Choice D rationale
Activating the emergency response team is premature unless the patient is showing signs of immediate life-threatening instability or total limb ischemia with absence of pulses. Decreased pulses require prompt attention, but the nurse must first perform a focused assessment to determine if a Doppler study is needed. Jumping to an emergency code without preliminary assessment can distract resources from other patients. The nurse should follow the clinical hierarchy of assessment, verification, and then appropriate notification based on the severity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Gasoline is a liquid hydrocarbon that can continue to damage the skin and be absorbed systemically if not removed immediately. Decontamination is the priority to stop the burning process and prevent further chemical injury to the client and exposure to healthcare staff. It involves removing saturated clothing and flushing the skin with water. This essential safety step must occur before other assessments or interventions to ensure the clinical environment remains safe for everyone.
Choice B rationale
Asking about the last meal is part of a secondary assessment, specifically for potential surgical intervention or intubation risks. While important for general anesthesia preparation, it does not address the immediate life safety threat posed by chemical contaminants on the body. In the hierarchy of trauma care, stopping the injury source through decontamination precedes gathering nutritional history. This information is valuable for preventing aspiration during later procedures but is not the primary safety concern.
Choice C rationale
Elevating the head of the bed is a standard intervention to reduce edema and improve respiratory excursion, especially in burn patients. However, this action is subordinate to the immediate need for decontamination in a chemical burn scenario. Respiratory support and positioning are part of the ABCs, but if the patient is still covered in gasoline, the chemical continues to destroy tissue. Decontamination is the unique priority here to stabilize the wound environment and prevent inhalation of fumes.
Choice D rationale
Determining the exact volume of gasoline encountered provides context for the severity of exposure but does not mitigate the current physical risk. While toxicological data is helpful for long term management, the immediate physical presence of the chemical on the skin is the emergency that requires action. Knowing the amount does not change the initial requirement for thorough irrigation and removal of the substance. Treatment focuses on clinical presentation and immediate neutralization of the causative agent.
Correct Answer is C
Explanation
Choice A rationale
This statement is physiologically incorrect because osteoarthritis does not involve rapid bone growth that enhances movement. Instead, the body may attempt to repair damaged cartilage by creating osteophytes or bone spurs. These bony projections actually restrict the range of motion in the joint and increase friction. Rather than reducing discomfort, these changes contribute significantly to the chronic pain and mechanical stiffness associated with progressive joint degeneration in patients.
Choice B rationale
The pathophysiology of osteoarthritis is not defined by repeated joint infections or scar tissue accumulation. While septic arthritis involves infection, osteoarthritis is primarily a non-inflammatory, degenerative condition. The stiffness felt by patients results from the mechanical breakdown of the joint structures rather than the presence of fibrotic scar tissue from previous infections. Attributing the disease to infection ignores the primary role of mechanical stress and chondrocyte dysfunction in the breakdown of articular cartilage.
Choice C rationale
This is the accurate description of the disease process as it involves the progressive degradation of hyaline cartilage. As the protective cartilage thins, the subchondral bone is exposed, leading to increased pressure and friction during movement. This bone-on-one contact triggers nociceptors and leads to the characteristic pain and crepitus. Understanding this wear and tear mechanism helps patients realize why weight management and joint protection are vital for managing their specific symptoms.
Choice D rationale
Osteoarthritis is not an autoimmune disorder; that description applies to rheumatoid arthritis. In rheumatoid arthritis, the immune system targets the synovium, causing systemic inflammation. In contrast, osteoarthritis is localized and characterized by the mechanical failure of the joint. While minor secondary inflammation may occur due to cartilage debris, the underlying cause is not a systemic immune attack. Proper identification is crucial because treatments for autoimmune conditions, like DMARDs, are not effective for osteoarthritis.
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