Question

A nurse is caring for a client following peripheral bypass graft surgery on the LLE. Which of the following findings pose an immediate concern? (Select all that apply.)

A. Trace of bloody drainage on dressing
B. Capillary refill of affected limb of 6 seconds
C. Mottled appearance of the limb
D. Throbbing pain of affected limb that is decreased following IV bolus analgesic
E. Pulse of 2+ in affected limb

Answer 1

An immediate concern after peripheral bypass graft surgery are signs indicative of poor perfusion such as a capillary refill time of 6 seconds and a mottled appearance of the limb.

Step-by-step explanation:

When caring for a client following peripheral bypass graft surgery on the left lower extremity (LLE), there are several findings that could pose an immediate concern. The findings that require crucial attention include:

• Capillary refill of affected limb of 6 seconds, which indicates poor perfusion to the tissue.
• Mottled appearance of the limb, suggesting compromised blood flow or possible graft failure.

A trace of bloody drainage on the dressing may not be unusual and a throbbing pain that decreases after IV bolus analgesic could be expected post-operatively, although should still be monitored. A pulse of 2+ in the affected limb is considered within normal limits. The immediate concerns are primarily related to signs indicating poor perfusion or potential graft complications.