The nurse is monitoring a client who has returned to the unit after arterial revascularization. The client reports pain in the affected limb that is similar to the pain experienced before the procedure. What is the nurse's best action?
a. Assess the peripheral pulses in the limb.
b. Elevate the affected extremity on pillows.
c. Administer pain medication as prescribed.
d. Place a warm blanket on the operative limb.
A
Ischemic pain may be present because the graft is occluded. The nurse would assess the limb for peripheral pulses and would notify the surgeon if pulses are not found. Graft occlusion is a surgical emergency, and the nurse must recognize this as a sign of graft occlusion. Elevating the extremity would further compromise blood flow. Covering the extremity or administering pain addresses only the clinical manifestations, not the cause, of compromised blood flow.
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