The nurse receives hand-off report on assigned clients. Which client should the nurse assess first?

Question

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Femoral-popliteal bypass surgery involves circumventing a blockage in the femoral artery with a synthetic or autogenous (artery or vein) graft to restore blood flow. The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color and skin temperature, capillary refill, pain, movement) and compares the findings with the preoperative baselines. The client's nonpalpable pedal pulse that is present only with Doppler distal to the graft (ie, post-tibial, pedal) can indicate compromised blood flow or graft occlusion and should be reported to the health care provider immediately. (Option B) Chronic venous insufficiency is the inability of the leg veins to efficiently pump blood back to the heart. It can lead to venous stasis, increased hydrostatic pressure, and venous leg ulcers. Edema and thick skin with brown pigmentation are expected manifestations, so this is not the priority assessment. (Option C) Gangrene of the foot is a complication of peripheral arterial disease (PAD) associated with decreased blood flow to the extremity. Coolness of the skin and shiny, hairless legs, feet, and toes are expected manifestations of PAD, so the nurse would not assess this client first. (Option D) Intermittent claudication is leg pain caused by decreased blood flow to the muscles that reoccurs during activity such as walking and dissipates with rest. It is an expected manifestation of PAD of the lower extremities, so the nurse would not assess this client first. Educational objective: Absent or decreased volume in the peripheral pulses distal to the graft can indicate compromised circulation or graft occlusion and should be reported to the health care provider immediately.

The Nurse Receives Hand-Off Report on Assigned Clients