Difficulty: Medium
Average Score: 67%
Simulated
A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first?
Correct answer
B
Rationale
A significant drop in blood pressure post-femoral-popliteal bypass graft suggests possible hypoperfusion or graft occlusion. Assessing pedal pulses first is critical to ensure the graft is patent and blood flow is restored to the lower extremity. Compromised pulses could indicate graft failure, requiring immediate intervention. IV fluid rate, nasal cannula flow rate, and capillary refill are secondary considerations after confirming vascular patency.