Home » NCLEX » NCLEX-PN » What action should the nurse perform next to prevent ischemia?
A client has just returned from surgery where a femoral-popliteal bypass was performed. The nurse has assessed the client and is unable to feel a pulse at either the dorsalis pedis or the posterior tibial sites of the left foot. The foot feels warm and the color is pink. What action should the nurse perform next to prevent ischemia?
A. Notify the physician immediately.
B. Obtain a Doppler device to check for pulses, and notify the physician if they are still absent.
C. Wait 30 minutes and recheck the pulses.
D. Document the finding.
Correct Answer: B
Explanation/Reference:
Explanation:
The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial can be difficult to assess and might need to be verified with a Doppler. Because the client just had a surgery in which a complication is arterial insufficiency, the client must be monitored carefully. If the pulses are not found, the nurse should recognize that this is an emergent situation, and the physician must be notified immediately. If the nurse waits 30 minutes before determining if the pulses can be felt, this could compromise the viability of the client’s foot due to ischemia. Documenting the findings is important but must be performed after the nurse locates the dorsalis pedis and posterior tibial pulses or any necessary interventions are made.Health Promotion and Maintenance
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