Practice Question
A nurse is caring for a client who is I day postoperative following a femoral popliteal bypass graft. The nurse notes a diminished pedal pulse while assessing the right leg. Which of the following actions should the nurse take?
Answer Choices:
Correct Answer:
Assess pedal pulse on left leg
Rationale:
🔷 Comparing the right leg pulse with the left leg pulse establishes whether the change is unilateral, which helps determine if the graft is compromised.
🔷 A diminished pulse in the operative leg may indicate graft occlusion, a surgical emergency requiring immediate evaluation.
🔷 Baseline comparison is essential, because the nurse must determine whether the diminished pulse is new or part of the client’s chronic vascular pattern.
🔷 Prompt assessment of both extremities helps identify impaired perfusion, which is the highest priority following vascular bypass surgery.
🔷 Early detection of graft failure greatly improves outcomes, making bilateral pulse assessment the most critical next step.
Elevate the right leg on pillows.
🔷 Elevation can reduce arterial blood flow, which may further compromise perfusion to an already ischemic limb.
🔷 Arterial bypass grafts require dependent positioning, not elevation, when perfusion is threatened.
Assist the client to ambulate.
🔷 Ambulation will not correct a diminished pulse, and may worsen ischemia or damage the graft.
🔷 Activity is contraindicated until perfusion is confirmed, because graft compromise requires immediate medical evaluation.
Assess surgical incision site for infection.
🔷 Infection does not cause an immediate diminished pulse, so this does not address the urgent perfusion concern.
🔷 Pulse changes indicate vascular compromise, not infection, making incision assessment a lower priority.
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This question is from RN Adult Medical Surgical 2023 Dec which contains 78 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 4