Question

the nurse provides care for a client who had a femoropopliteal bypass graft in the right leg 4 hours ago. which appropriate (select all that apply.)

1. places the client in a chair for 30 minutes.
2. accurately records intake and output.
3. assesses for pulses in the right leg every 4 hours.
4. encourages the client to cough and deep breathe.
5. elevates the client’s legs.

Explanation:

1. After a femoropopliteal bypass graft, the client should avoid sitting for long (like 30 minutes in a chair) as it can impede blood flow, so 1 is inappropriate.
2. Accurately recording intake and output is appropriate for fluid balance monitoring, so 2 is appropriate (not inappropriate).
3. Assessing pulses in the right leg every 4 hours is too infrequent; more frequent assessment (e.g., hourly initially) is needed to monitor graft patency, so 3 is inappropriate.
4. Encouraging cough and deep breathe helps prevent respiratory complications, which is appropriate (not inappropriate).
5. Elevating the legs can reduce blood flow to the grafted area, so 5 is inappropriate.

So the inappropriate actions are 1, 3, 5.

Answer:

1. Places the client in a chair for 30 minutes.
2. Assesses for pulses in the right leg every 4 hours.
3. Elevates the client’s legs.