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NCLEX-RN · Question #314

A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:

The correct answer is B. Notify the physician immediately. (A) The client is losing blood supply to his left foot. Continuing to monitor the foot will not help restore the blood supply to the foot. (B) The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the…

Physiological Integrity: Reduction of Risk Potential

Question

A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:

Options

  • AContinue to monitor the foot
  • BNotify the physician immediately
  • CReposition and reassess the foot
  • DAssure the client that his foot is fine

How the community answered

(19 responses)
  • A
    16% (3)
  • B
    74% (14)
  • C
    5% (1)
  • D
    5% (1)

Explanation

(A) The client is losing blood supply to his left foot. Continuing to monitor the foot will not help restore the blood supply to the foot. (B) The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the foot and/or leg. (C) The presenting symptoms are of an emergency nature and require immediate intervention. (D) This action would be giving the client false assurance.

Topics

#femoral popliteal bypass#graft occlusion#vascular assessment#emergency response

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