This question has been bugging my class...

[mr cooper]

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.

[classicdame, MSN, EdD]

there are lots of signs that a patient may present. Pedal pulse is one. But the VITAL SIGNS are the ones that are most important (hence the name!). The limb ischemia is being caused by poor circulation. One way to judge circulation is BP and Pulse. I would always get VS first. If nothing else, the MD will want that info if you end up calling.

[drowningdaily]

I would go with B. Unless pt was unresponsive. Question does not say he is unresponsive. In reality a nurse would slap on a bp cuff and assess pulse and get vitals at same time. But, circulation is priority.

[4boysmama]

I thinkt he critical piece of info in the question stem is "just arrived" from the procedure. You'd do vitals first and then the rest of assessment (including pedal pulses) Now, in reality, you'd probably have the monitor doing vitals, so you'd be able to do both at the same time. but for testing purposes, I believe the answer is A. Need to make sure pt isn't dead before you worry about the leg...or, in other words, make sure the heart is perfusing (BP and pulse) before you worry about extremities perfusing.

[meanmaryjean, DNP, RN]

I must be thick...... my thought was vitals, but for a completely different reason. The scenario does not say which limb was treated. My thought was "Why check pedals if it was an UPPER extremity which had the limb ischemia?" Clearly, I need more coffee

*Shuffles off to the coffee pot.........

[AgentBeast, BSN, RN]

Initially do we really care if the patient has blood flow in their extremities? So what if they don't! They aren't going to die if they don't. If they are bleeding out or have lost a ton of blood initially their HR will be high and later their BP will be low. Bleeding out will kill them. If they can use their arms and legs is secondary to being alive. We can worry about the circulation in their extremities once we work out whether they are bleeding out or not.

[Best_Name_Ever]

I say B.

ABCs. Airway,breathing, circulation.

Circulation would include checking pedal pulses.

Priority after an angio is always checking the site for bleeding and checking pedal pulses.

[LadyFree28, BSN, LPN, RN]

The distractor, to me is the limb ischemia. That may be the diagnosis, and the pt returned from the procedure, which is focused in circulation; the ABCs. Baseline assessment does call for both; however, the BP pulse gives you a measurable picture if there are additional complications. If a pt has limb ischemia, the anticipation of weak-no pulse is apparent, this person has an circulation issue, and they underwent a procedure that can produce many complications, including shock. BP and pulse is important in determining shock. So A is the more appropriate answer.

[Stephalump]

I agree, the pulses are a distraction.

Your priority is to catch any life-threatening post-procedure complications ASAP.

[acerbia]

I would go with B. Unless pt was unresponsive. Question does not say he is unresponsive. In reality a nurse would slap on a bp cuff and assess pulse and get vitals at same time. But, circulation is priority.

Right, but technically you'd be gathering the vitals first because you put the BP cuff on. Unless you can put a BP cuff on with one hand while taking the pulse with the other! lol Nursing exams are deliberately tricky with their line of questioning.

[MunoRN, RN]

Teachers will tell you never assume anything that isn't in the question, which isn't possible. The question makes no mention of it, but I have to assume I haven't walked in to find the patient's head no longer attached to their body, but I have to assume that is the case to accept any of the options. In reality, the answer is B, in Nursing school though it could be anything depending on all of those factors that the writer of the question assumed but didn't include in the question (such as whether or not their head is still attached to their body).

Given the reality of having to make some assumptions, the first thing that gets checked is pulses. This is because a post-op patient has been getting frequent vitals and is accompanied by their PACU RN (an assumption, but no less of an assumption than assuming they were just given a map and told to walk to the Nursing unit). If the patient was conscious and alert and is now suddenly, unarousable, then the ABC's are your priority, although this would be more of an stretch than assuming this is not the case, plus, the presence of pulses is going to be your first circulation assessment in either case. If I introduce myself to the patient prior to doing anything and they tell me their name, then I've established airway patency and established they have enough circulation to be conscious and provide appropriate answers to questions. Since I have no reason to check vitals emergently (no reason to was provided in the answer and the more reasonable assumption is that there have been no acute changes since their last vitals which was not more than 15 minutes ago typically), the most important thing at the time when you have the previous Nurse at the bedside is to establish the pulses have not changed, which unlike HR and BP which are strictly quantitative, pulses have much more of a qualitative component, in which a baseline is best established with a simultaneous check.

I wouldn't be surprised of the whoever wrote the question was looking for answer A, although that's kind of a ridiculous rationale when you think about it. If the rationale for A is that you need to assess for a life threatening HR or BP, then one can't claim you aren't doing that in both A and B, checking pulses includes a basic check of both HR and perfusion, so really A and B are the same answer except B includes more data. Exact vitals are definitely important (as opposed to a basic check of HR and perfusion), but the indication for checking those is not that they need continuous checking just for the heck of it. For some patient, continuous BP monitoring is indicated, but if it's not we establish a frequency of checks that is appropriate based on their condition, history, etc. and check at that frequency and more often as indicated by other assessment factors, without any evidence that there other assessment factors present, checking vitals outside of those frequencies isn't indicated, although checking pulses with the previous Nurse is.

[LadyFree28, BSN, LPN, RN]

This question is probably going to get "thrown out" or both A and B will be accepted. I would live to know what happens...

[hodgieRN]

Pedal pulses on a critically ischemic leg that required an intervention is priority. You are assessing if the procedure was successful. This is how NCLEX questions are based. A HR and BP doesn't indicate anything about the circulation to the critically ischemic leg. The word critically is the hint. Critical leg. You can't assume that the pt is unstable or that the BP is nonexistent. No pulses in a critically ischemic leg is an emergency. Having no HR is an emergency, but the question said nothing of an absent HR.

If a question states that pt had an traumatic arm amputation and was profusely bleeding, the answer wouldn't be heart rate and blood pressure...the answer would be to stop the bleeding. Yes, you could say that if a pt was bleeding out, then the bp would drop and the HR would stop and eventually, the pt would die. But the question is asking the proper intervention to bleeding. It's an intervention question. If a arterial sheath started bleeding, the first thing you do is apply pressure. You don't get the blood pressure first.

If a pt was admitted with a history of frequent falls and the side rail is found down...and you have a choice of getting a HR and BP or put the side rails up, the answer is put the side rails up. Its a question about safety. Wouldn't you argue that HR and BP is more important? It's ABC's isn't it? Isn't a stable HR more important than someone that is at risk for falls? That is not what the question is asking. It wants to know if you can answer the question with the information provided only.

You have to pick out if it is an assessment question, an intervention question, an evaluation question, a safety question, etc. A HR doesn't tell you anything about perfusion to the leg. You can't assume that the pt is dead until you get vital signs. And, you can't assume that you would get vital signs as you are assessing pulses. The answer would be a HR and BP is it said a pt with a critically ischemic leg arrived to the unit who was reported to be hypotensive during surgery. Or, if it mentioned that the pt was unresponsive. Then, the leg is not as important.

You have to say this to yourself. You have one thing you are allowed to do. The doctor is standing there and needs an answer to a question. You can choose to check the pulses in the critically ischemic leg (which mean that there was no blood flow and the pt is at risk for losing the leg) or you don't check the pulses, only get vital signs and walk away. There is nothing that indicates that the pt is hemodynamically unstable in the first place. I would think the pulses are priority in this situation. People may think pedal pulses are not important, but if you have ever taken care of a pt that has a severed artery, there is nothing more important...especially when there is no information of assumed hypotension or bradycardia.