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: Option B is the most appropriate action, as using a Doppler device allows for a more accurate assessment of blood flow and pulse presence, which is crucial after vascular surgery. If pulses remain absent, notifying the physician promptly is essential to prevent potential ischemia.
Option A, while important, is premature without further assessment. Immediate notification may not be warranted if a Doppler can provide more information.
Option C delays intervention; waiting 30 minutes could risk worsening ischemia if there is an actual blockage.
Option D lacks urgency and does not address the immediate risk of ischemia that requires intervention.