Practice Quiz

NCLEX-RN

Category - Physiological

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A client was inserted with an intra-aortic balloon pump 24 hours ago through the left femoral approach. On assessment, the nurse finds that the left foot is cool and left pedal pulse weak. The initial action of the nurse is to:
  1. Document the findings as normal
  2. Re-assess the client’s neurovascular status in 30 minutes
  3. Elevate the left extremity
  4. Notify the physician immediately
Explanation
Answer: D - The neurovascular status of the client with an intra-aortic balloon pump must be monitored by being alert for signs of occlusion, such as coolness of the extremity, pain and an absent or weak pulse. These findings must be reported to the physician immediately.
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