2024 PN NCLEX Questions Nursing Practice Question
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?
Correct Answer: B
Rationale: The best action is to obtain a Doppler device to check for pulses and notify the physician if they remain absent. This approach allows for a more accurate assessment of blood flow, as a Doppler can detect weak or absent pulses that may not be palpable.
Option A, notifying the physician immediately, may be premature without first confirming the absence of blood flow with a Doppler. Option C, waiting 30 minutes to recheck pulses, delays necessary intervention, risking potential ischemia. Option D, documenting the finding, is important but does not address the immediate concern of assessing blood flow and preventing complications.