hard · NCLEX-RN Reduction of Risk Potential

The nurse is caring for a client who is 12 hours postoperative from a femoral-popliteal bypass graft. The client's pedal pulse on the operative side was previously 2+ and is now only palpable with a Doppler. The foot is cool to the touch.

What is the priority nursing intervention?

  1. Notify the surgeon immediately of the change in neurovascular status.
  2. Document the finding and re-evaluate the pulse in one hour.
  3. Wrap the foot in a warm blanket to improve peripheral circulation.
  4. Encourage the client to perform ankle pumps to stimulate blood flow.

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