Question

A nurse is caring for a client who is 4 hr postoperative following an arterial revascularization of the femoral artery. Which of the following actions should the nurse take? A. Place a foam pillow under the client's knees. B. Mark the iocation of the dient's distal pulses. C. Assess the client's affected extremity cvery 2 hr. D. Evaluate the clients ankle brachial index (ABI) once every 48 hir.

Answer 1

The nurse should mark the location of the client's distal pulses after an arterial revascularization of the femoral artery to monitor adequate blood flow and detect any potential complications.

Step-by-step explanation:

The correct action that a nurse should take for a client who is 4 hours postoperative following arterial revascularization of the femoral artery is Mark the location of the client's distal pulses. This is essential to monitor the vascular status of the affected limb and ensure that blood flow is adequate. It's important to document the presence and quality of the pulses at regular intervals, as a change could indicate a complication. Placing a foam pillow under the knees (option A) can result in pressure behind the knee and reduce circulation, potentially compromising the surgical site. It is recommended to assess the client's affected extremity more frequently than every 2 hours, typically every 15 to 30 minutes initially and then hourly as the patient stabilizes (option C). While the Ankle Brachial Index (ABI) is a useful diagnostic tool, it is not typically measured as frequently as once every 48 hours in the immediate postoperative period (option D).

Answer 2

The nurse should mark the location of the client's distal pulses and regularly assess the client's affected extremity, which is a crucial component of immediate postoperative care following femoral artery revascularization to promptly detect any changes that may indicate complications.

Step-by-step explanation:

The proper action a nurse should take when caring for a client who is 4 hours postoperative following an arterial revascularization of the femoral artery includes assessing the client's affected extremity. The nurse should mark the location of the client's distal pulses to keep track of pulse strength and detect any changes promptly, which might indicate a complication like a blockage or reduced blood flow. Furthermore, it is essential to assess the client's affected extremity regularly - every 15 minutes initially, then every hour for a few hours, and then less frequently as per the hospital protocol, but certainly more often than every 2 hours. This is crucial to monitor for signs of compartment syndrome, bleeding, thrombosis, or other vascular complications. The use of a blood pressure cuff and a stethoscope are standard for different measurements, but monitoring postoperative pulses is typically a manual process. Placing a foam pillow under the knees or evaluating the ankle brachial index can be part of ongoing care, but are not the most immediate postoperative actions for monitoring arterial revascularization.