A client had a percutaneous transluminal coronary angioplasty for ...

[Kthamas]

A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met?
 
  a. Pain rated as 2/10 after medication
  b. Distal pulse on affected extremity 2+/4+
  c. Remains on bedrest as directed
  d. Verbalizes understanding of procedure

Question 2

A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?
 
  a. Administer pain medication as ordered.
  b. Assess distal pulses and skin color.
  c. Document the findings in the client's chart.
  d. Notify the surgeon immediately.

[beccamahon]

Answer to Question 1

ANS: B
Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.

Answer to Question 2

ANS: B
Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse should assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines the client's perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.