Medical Surgical Peripheral Vascular Disease #8

Question

A nurse is caring for a client who returned from surgical popliteal bypass graft procedure. A priority assessment during the first 24 hours will include:

Answers

  1. Assess pulse of affected extremity every 15 minutes, followed by agency policy.
    • Rationale:

      This answer is correct because after the popliteal artery is opened by a bypass graft procedure, the graft can malfunction and return to being blocked. This is a medical emergency. The nurse’s priority assessment the first 24 hours is assessment of the pulse of the affected extremity every 15 minutes, followed by agency policy. Significant decrease or loss of the pulse should be immediately reported to the surgeon.

  2. Palpate the affected leg for pain and venous return during every assessment.
    • Rationale:

      This answer is not correct because palpating the affected leg for pain is contraindicated and can cause unnecessary pain. Assessing venous return is not the priority over assessment of arterial perfusion of the affected leg. The nurse’s priority assessment the first 24 hours is assessment of the pulse of the affected extremity every 15 minutes, followed by agency policy. Significant decrease or loss of the pulse should be immediately reported to the surgeon.

  3. Assess the client for signs and symptoms of compartment syndrome every 2 hours.
    • Rationale:

      This answer is not correct because compartment syndrome usually occurs with injury or a cast, not following a bypass graft procedure. The nurse’s priority assessment the first 24 hours is assessment of the pulse of the affected extremity every 15 minutes, followed by agency policy. Significant decrease or loss of the pulse should be immediately reported to the surgeon.

  4. Perform Doppler evaluation once daily.
    • Rationale:

      This answer is not correct because doppler evaluation of the pulse would only be needed if the pulse was not palpable. Then, if it is not palpable, it should be dopplered much more than once daily post-operatively. The nurse’s priority assessment the first 24 hours is assessment of the pulse of the affected extremity every 15 minutes, followed by agency policy. Significant decrease or loss of the pulse should be immediately reported to the surgeon.

Overview

The priority assessment during the first 24 hours following a popliteal bypass graft procedure is assessment of the pulse of the affected extremity every 15 minutes, followed by agency policy.

Explanation

Learning Outcomes

A popliteal bypass graft is needed when a client experiences a blockage of the popliteal artery, which decreases perfusion to the lower leg and foot. The blocked artery is bypassed with the client’s donor vessel placed as a graft to restore blood flow to the extremity. After the artery is opened, the graft can malfunction and return to being blocked. This is a medical emergency. The nurse’s priority assessment the first 24 hours is assessment of the pulse of the affected extremity every 15 minutes, followed by agency policy. Significant decrease or loss of the pulse should be immediately reported to the surgeon.

Test Taking Tip

Unless the airway or breathing is at risk or compromised, checking for circulation is the priority assessment after surgery on a client’s artery

Video Rationale