A patient on whom an endovascular repair of the aorta has just been performed is now complaining of numbness and tingling in the toes
The nurse inspects the patient's legs and discovers weak pulses bilaterally, cool lower extremities, and capillary refill greater than 3 seconds. What immediate nursing action is indicated? 1. Contact the patient's family to come to the hospital.
2. Instruct the patient to take deep breaths to increase oxygenation.
3. Contact the ECG technician to get an ECG because the patient is likely having a heart attack.
4. Contact the health care provider because the patient has likely developed interruption of arterial flow.
4
Rationale 1: The family should be contacted if the patient wishes, but this is not the priority.
Rationale 2: Taking deep breaths will increase oxygenation but will not affect blood flow to the lower extremities.
Rationale 3: The patient is not having a heart attack; therefore, completing an ECG is not a priority.
Rationale 4: Numbness, tingling, weak pulses, and signs of poor perfusion all indicate interruption of arterial flow. Interruption may be caused by thrombus and is an emergent situation requiring intervention by the health care provider.
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