A client who has just completed an endovascular repair of the aorta is now complaining of numbness and tingling in his toes
The nurse inspects the client's legs and discovers weak pulses bilaterally, cool lower extremities, and capillary refill greater than 3 seconds. The nurse should immediately: 1. Contact the health care provider because the client has likely developed a thrombus, blocking the artery.
2. Contact the client's family to come to the hospital.
3. Instruct the client to take deep breaths to increase oxygenation.
4. Contact the ECG technician to get an ECG because the client is likely having a heart attack.
Contact the health care provider because the client has likely developed a thrombus, blocking the artery.
Rationale: Because the client is experiencing numbness, tingling, weak pulses, and signs of poor perfusion, the client is likely experiencing a thrombus that is blocking the femoral arteries. The health care provider will need to be contacted immediately to evaluate the client. Contacting the client's family should only be done if the client wishes, but this is not the priority. Instructing the client to take deep breaths will increase oxygenation, but will not impact the blood flow to the lower extremities. The client is not having a heart attack; therefore, completing an ECG is not necessary.
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