The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first?

Question

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The nurse should assess the pulses (eg, femoral, posterior tibial, dorsalis pedis) and skin color and temperature of the lower extremities in the client with the abdominal aortic aneurysm (AAA) repair first. Pulses can be absent for 4-12 hours after surgery due to vasospasm. However, a pedal pulse decreased from the client's baseline or an absent pulse with a painful, cool, or mottled extremity 2 days postoperative can indicate the presence of an arterial or graft occlusion. This client's condition poses the greatest threat to survival. (Option B) An elevated white blood cell count (>11,000/mm³ [11.0 x 10⁹/L]) could be caused by an underlying infection or the stress of the surgery. This needs to be assessed as soon as possible, but it does not take priority over the possible limb loss with graft occlusion. (Option C) A decreased ejection fraction (normal 55%-70%) results in decreased cardiac output and inability to meet oxygen demand, leading to shortness of breath and activity intolerance. The nurse should assess lung sounds. However, this is an expected finding, so the nurse does not need to assess this client first. (Option D) Subcutaneous emphysema is air in the tissue surrounding the chest tube insertion site and can occur in a client with a pneumothorax. The nurse should assess lung sounds and palpate to determine the degree of emphysema. However, this is an expected finding, so the nurse does not need to assess this client first. Educational objective: A pedal pulse decreased from baseline or an absent pedal pulse and a cool or mottled extremity in a client who is postoperative abdominal aortic aneurysm repair can indicate the presence of an arterial or graft occlusion and poses the greatest threat to survival.

The Nurse on the Step-Down Cardiothoracic Unit Receives the Change-Of-Shift