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.

[LadyFree28, BSN, LPN, RN]

No one said pedal pulses are not important. I took "critical limb ischemia" as what the pt had and "just came back from percutaneous balloon angioplasty" and "what would you do FIRST" as the guide to what I am going to do.

The pt came back from the procedure; you are going to perform VS, and check pulses. There is only one answer; BP and pulse are measurable indicators of perfusion, in addition to pulses; however, shock is measure by BP and pulse.

The pt may still have a weak or no pulse because the pt ALREADY has critical limb ischemia. If the question was asking what would indicate a complication or whether the treatment was effective, then B would be an appropriate answer. If the question was worded ONLY about "critical limb ischemia" then B would be a more appropriate answer.

This question is asking what action you would take first post procedure, that is what I think.

I'm sure I have this question in my NCLEX review book...

[Stephalump]

From on of those "alert boxes" in my med-surg textbook:

"The priority for nursing care following a PTA or atherectomy is to observe for bleeding at the arterial puncture site, which is usually sealed with special collagen plugs. Monitor for manifestations of impending hypovolemic shock, including a decrease in blood pressure, increased pulse rate, and decreased urinary output. Perform frequent checks of the distal pulses in both legs to ensure adequate perfusion and oxygenation."

My professor would probably throw that question out if it was on a test, but I still think the better answer is A. Go ahead and lose a leg...I'd prefer you not go into shock. I don't think the focus of the question was on the ischemia, but on the fact that the pt was fresh out of a procedure. But once again...bad question.

[LadyFree28, BSN, LPN, RN]

Thanks Stephalump!!'

The answer IS A.

I swore this question was in my Saunders flash cards for the NCLEX...

As for the leg...yeah, they can fix that once they stabilize the shock, if you think about it...

[MunoRN, RN]

If the question included "on report the PACU Nurse tells that since the patient came out of surgery 90 minutes ago, they haven't done a single set of vitals". In that situation, absolutely, vitals are first on the list. If the patient just had vitals done 5 minutes ago, and even though there's been no change to suggest an immediate need to do another set of vitals before they are scheduled, the rationale is that you must do them at any given time to ensure the potential for shock is avoided, are you as the receiving Nurse going to continue to do vitals every 5 minutes perpetually? That seems a little ridiculous, but that's the argument behind answer A.

[hodgieRN]

Now the guy is in shock...

[hodgieRN]

From on of those "alert boxes" in my med-surg textbook:

"The priority for nursing care following a PTA or atherectomy is to observe for bleeding at the arterial puncture site, which is usually sealed with special collagen plugs. Monitor for manifestations of impending hypovolemic shock, including a decrease in blood pressure, increased pulse rate, and decreased urinary output. Perform frequent checks of the distal pulses in both legs to ensure adequate perfusion and oxygenation."

This paragraph wasn't written in a specific order. Just because the sentence about pulses is at the end, doesn't make it the last priority. If that was the case, then decreased urine output had more priority over pulses.

Notice it says priority following a PTA is to observe for bleeding. Monitoring for manifestations of impending hypovolemic shock, decreased BP, and increased HR all have to do with bleeding. If the pt is not bleeding, then there is no shock, no low BP, and no increased HR. The pt is stable. The priority for a stable pt is peripheral pulses.

Go ahead and lose the leg? The question said nothing of picking between pulses or stabilizing a pt that was in shock. The pt is not going to go into shock. The question said nothing of bleeding. The answers didn't even offer the choice of assessing the site for bleeding. That's b/c the pt isn't bleeding. He is stable. The stable pt isn't going to go into shock. The BP doesn't tell if the the procedure was successful.

Keep in mind that the question does not say that the pt arrived in PACU right out of surgery. It's say "he went to the nursing unit," meaning the pt was stable enough to be transferred to the floor. Why would this guy magically be in shock. The priority for a PTA is to check perfusion, motion, and sensation to see if the procedure was successful.

If you walked into a room and a pt said "I just had surgery earlier. I can't feel anything in my hand and my arm is cold and blue." You would dive right to the radial pulse. You wouldn't say "Ok. Let me get the monitor ready so I can take your vital signs. You can go ahead and lose the arm."

[Stephalump]

This paragraph wasn't written in a specific order. Just because the sentence about pulses is at the end, doesn't make it the last priority. If that was the case, then decreased urine output had more priority over pulses.

Notice it says priority following a PTA is to observe for bleeding. Monitoring for manifestations of impending hypovolemic shock, decreased BP, and increased HR all have to do with bleeding. If the pt is not bleeding, then there is no shock, no low BP, and no increased HR. The pt is stable. The priority for a stable pt is peripheral pulses.

Go ahead and lose the leg? The question said nothing of picking between pulses or stabilizing a pt that was in shock. The pt is not going to go into shock. The question said nothing of bleeding. The answers didn't even offer the choice of assessing the site for bleeding. That's b/c the pt isn't bleeding. He is stable. The stable pt isn't going to go into shock. The BP doesn't tell if the the procedure was successful.

Keep in mind that the question does not say that the pt arrived in PACU right out of surgery. It's say "he went to the nursing unit," meaning the pt was stable enough to be transferred to the floor. Why would this guy magically be in shock. The priority for a PTA is to check perfusion, motion, and sensation to see if the procedure was successful.

If you walked into a room and a pt said "I just had surgery earlier. I can't feel anything in my hand and my arm is cold and blue." You would dive right to the radial pulse. You wouldn't say "Ok. Let me get the monitor ready so I can take your vital signs. You can go ahead and lose the arm."

I didn't say anything about the paragraph being in order, just that those were the listed priorities.

NCLEX questions aren't that interesting. They don't care about a back story, they don't care about your literally step by step actions...they just want you to demonstrate knowledge.

All that matters is that this questions either wants to know priority post-OP care (which would be A) or priority assessment of the effectiveness. All it is about is key words, not a long tale of logic or over-complication.

Which it's actually testing over? Obviously a point of contention, which is why it's a bad question.

[MunoRN, RN]

I agree we should be watching for impending shock in any patient, although I disagree that there is anything presented in the question that suggests the need for continuous vitals signs. All post procedure patients have a set frequency of vital signs for the purpose of assessing for changes in the patient. We follow this frequency unless something indicates doing them more often. There's nothing in the question to suggest that indicates the need for an additional set of vitals outside of the set parameters. Unlike vitals, which aren't going to very much based on the observer, site checks and pulse checks are far more subjective, and obtaining a baseline is key.

If the rationale is that the patient should go into shock, so vitals are the priority at any given time, wouldn't you have to then check vitals continuously from that point forward? I would think making this a priority without any particular reason, at the expense of all your other patients who you won't see for the rest of your shift because you're doing continuous vitals on your post-peripheral-intervention patient for no particular reason, would be a poor decision.

[LadyFree28, BSN, LPN, RN]

This question is based in NCLEX world...unfortunately...hope the OP comes back and has the answer.

[redtailhawk]

I would choose B.. You must consider the stem and address the priority in this specific circumstance. I agree with the OP..