The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass
graft procedure. Which of the following assessments requires immediate notification of the health
care provider
...
The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass
graft procedure. Which of the following assessments requires immediate notification of the health
care provider?
Left foot is cool to the touch
Absent left pedal pulse using Doppler analysis
Inability to palpate the left pedal pulse
Acute pain in the left lower leg
Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left
lower leg are important findings, they all require additional nursing assessment prior to contacting the
health care provider. In clients without palpable pedal pulses, the next step in the assessment is to
perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis
requires immediately notifying the health care provider.
Ref # 1028
There's a new medication order that reads: "administer 1 gtt ciprofloxacin
solution OD Q 4 h" What action should the nurse take?
Call the prescriber to clarify and rewrite the order
Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors.
"OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating
medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the
official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a
potentially dangerous "workaround." The nurse should call the health care provider who prescribed the
medication and clarify the order.
Ref # 1440
Which individual is at greatest risk for the development of hypertension?
45 year-old African-American attorney
The incidence of hypertension is greater among African-Americans than other groups in the United
States. The incidence among the Hispanic population is rising.
Ref # 2446
A woman, who delivered five days ago and who had been diagnosed with
pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to
ask for advice. She states, "I have had the worst headache for the past two days.
It pounds and by the middle of the afternoon everything I look at looks wavy.
Nothing I have taken helps." What should the nurse do next?
Ask the client to stay on the line, get the address, and send an ambulance to the hom
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