This question has been bugging my class...

Nursing Students Student Assist

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Here it is:

When caring for a patient who has critical limb ischemia who has just arrived on the nursing unit after having a percutaneous transluminal balloon angioplasty, which action should the nurse take first?

A. Take the BP and pulse rate

B check for the presence of pedal pulses

C assess the appearance of any ischemic ulcers

D start discharge teaching about antiplatelet drugs.

My thought is B as did everyone else initially, but othe people are saying A. I'm sticking with B because pedal pulses are the key indicator of for the success of this surgery while BP is not specific. A high BP does not guarantee perfusion. Pedal pulse check is a direct check of limb perfusion.

Specializes in pediatrics, orthopedics.

But the question didn't ask what the best indicator of pedal perfusion is, it just wants to know the first action you'd take. You've got a fresh post-op patient being admitted, not someone who's been on the floor a while. ABCs. Vitals first, then CMS assessment. Think of it this way: if his BP is zero you're not going to have a pedal pulse and you will have just wasted time assessing CMS when you could have been calling a code!

I see. That does make sense. Vitals first for a new person on the floor.

Specializes in Forensic Psych.

I'd go with A. Sometimes there's a difference between a "what to do first" question and a priority question.

Even in the case of priority interventions, I'd still say BP and pulse were priority. Assessment of life-threatening complications from the pts procedure trumps whether or not this procedure actually worked.

You have a new patient on the floor always check vitals. You need to get baseline data so you can have something to compare to down the line. B is a great answer but not the initial thing you do. Taking vitals is part of assessment and assessment is always done before implementation. Answer is A

Specializes in ER trauma, ICU - trauma, neuro surgical.

So, this is my take on it....

Pulses are not automatically put in the CMS portion because blood pressure in any other case is more important. The pt is not going to have a BP of zero and a code chart is not going to be called. The question said nothing of hypotension and it is not asking what may happen because something might turn into this, which might turn into this, which may lead to this. You have the answer the question based only on the information given to you. You can't throw in hypotheticals in the real world or say what you would really do on the floor.

The question is asking for the specific assessment/evaluation of a pt with critically leg ischemia who required an intervention. Your answer is supposed to reflect whether or not the intervention was successful. A heart rate does not say anything about the perfusion of the leg with ischemia. A peripheral pulse check will.

The bp and heart rate choice is there to trick you. They know that you are going to lean toward that because what else is more important than bp and a heart rate, right? Then, if you lose your bp, then this will happen, and this will happen, and the sky will fall down. If you do this for test questions, you will fail. You have to answer the question, not pick the most important choice which applies to all areas of the real world. A heart rate and a BP is important in the general sense, but that doesn't say whether or not the leg is getting perfused.

Yes, you would check vital signs on a new post-op pt, but it is not asking you what you would do for a new post-op pt in the real world. It is asking you about perfusion in a critically ischemic leg. The blood pressure says nothing about the intervention. Someone who doesn't have pedal pulses after an intervention is pretty important.

ABC stands for airway, breathing, circulation. Pulses are circulation, even the pedals. Circulation isn't just the carotid during a code. So, pedal pulses is apart of your ABC's; not the CMS portion.

My initial thought is B. My concluding answer is B. IF I were the nurse I would want to make sure their leg is being perfused. I would later carry out A.

Foot*

BTW ... I also see why A could be right...

So ... I AM a bit on fence. Hmm..

Couldn't I let the BP machine do its thing as I check pulse and respiratory rate (in real world nursing) ? Hehe

Specializes in Trauma | Surgical ICU.

The answer is B

PTCA is done by inserting a needle through the groin area. When PTCA (or like procedures), always check for circulation, motion and sensation. This way you are ensuring that the patient is getting adequate perfusion on the incision site.

Specializes in Infusion Nursing, Home Health Infusion.

I say B....I would go right to that limb and start looking for pulses and doing an assessment then I would get official vital signs. Remember that you will be able to see, feel and touch the patient and will have a good idea of generally how thy are doing by their overall color,temperature of skin..ect. You can also call for assistance and have someone else get VS while you are checking the limb.

This is all about 'playing the game'.

The key word / phrase in this question is ''what would you do first"

Often this is substituted by ''what is priority''

They try to play little tricks on you.

A bride was shot in the leg and is in the ER crying about blood on her dress and missing her wedding, what do you do first?

Sorry sweety, the dress can be replaced, right now we need to see if you're dying

I'm in Medsurg 1 and we're often given ''what would you do first?"

First thing:

Are they alive? Are they trying to die on you?

What is indicitive of alive?

ABC's

How do we assess ABC's?

If they're in V-tach or anything the leg will have to wait. If the pressure is in the toilet than the leg isn't being perfused anyway.

This is the same reason why a patient coming into the ER might have to be hungry for a little while.

We have to make sure you're not dying. You won't be hungry if you're dead. :sarcastic:

Specializes in CMSRN.

I would also go with A on this one. The BP and pulse rate are going to give you your baseline and from there you would go in to the more specific areas, such as the pedal pulses.

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