When providing preoperative care for a client with an abdominal aneurysm, changes in which assessment finding are most important for the practical nurse (PN) to report to the registered nurse (RN)?

Choice A reason: Evaluating the return of the gag reflex is important for assessing a client's ability to protect their airway and for readiness to eat or drink after surgery. However, it is not the immediate priority when a client is repeatedly swallowing, which can indicate bleeding.
Choice B reason: Demonstrating relaxation techniques can be beneficial for managing pain and anxiety, but it does not address the immediate concern of potential postoperative bleeding in a client who is repeatedly swallowing.
Choice C reason: Using a penlight to assess the pharynx for bleeding is the priority action. Repeated swallowing after rhinoplasty can indicate bleeding, and assessing the pharynx allows the nurse to identify and address any postoperative hemorrhage promptly.
Choice D reason: Administering an intravenous analgesic per PRN protocol may help manage pain, but it is not the priority action. The primary concern is to check for potential bleeding, which is indicated by the repeated swallowing.

Choice A reason: Bathing the wound daily with soap and water is a common practice to maintain cleanliness and prevent infection in a wound. However, this is not the immediate priority in this scenario. The presence of a dusky color on the left foot indicates potential vascular compromise, which needs to be assessed first to ensure adequate blood flow to the affected area. Cleaning the wound can be done subsequently, but checking circulation is critical to address any immediate risks.
Choice B reason: Recording the color and temperature of the leg is an important assessment step to monitor the client's condition. These observations can provide valuable information about the client's peripheral circulation and skin condition. However, while this should be done as part of the overall assessment, it is not the most immediate action. Checking the pulses will give more direct information about the blood supply to the affected area, which is crucial for identifying any urgent circulatory issues.
Choice C reason: Performing dorsiflexion and extension exercises can help maintain joint mobility and muscle strength in clients with diabetes. However, it is not the first intervention that should be implemented in this scenario. Before recommending exercises, it is essential to assess the vascular status of the client's foot. Exercises may not be appropriate if there is significant circulatory compromise, and could potentially cause further harm.
Choice D reason: Checking the client's dorsalis pedis and posterior tibialis pulse points is the most critical first intervention. The dusky color of the foot suggests a possible issue with blood flow. By assessing the pulses in the foot, the practical nurse can determine if there is adequate perfusion to the area. If the pulses are weak or absent, it may indicate peripheral artery disease or another vascular issue that requires immediate medical attention. Prompt identification and intervention are crucial to prevent further complications, such as tissue necrosis or limb-threatening ischemia.