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Difficulty: HardBasic Care and Comfort

During early morning rounds, the practical nurse encounters an older adult client who recently underwent a right femoral-popliteal arterial bypass. The client appears highly agitated, is trying to climb over the raised side rails, and incorrectly believes they are at a train station. The nurse observes that the client's right knee is sharply flexed against the side rail. Which initial action should the nurse prioritize to maintain proper body alignment and ensure client safety?

  1. Carefully reposition the client to the center of the mattress with the right leg fully extended, and remain at the bedside to provide verbal reorientation.Answer
  2. B
    Apply a vest safety device to secure the client in the bed and prevent accidental disruption of the surgical incision.
  3. C
    Elevate the right extremity on multiple pillows above the level of the heart to promote comfort and reduce tissue edema.
  4. D
    Acknowledge the confusion as an expected finding of advanced age and step into the hallway to quickly gather a bed-exit alarm.

Answer

Carefully reposition the client to the center of the mattress with the right leg fully extended, and remain at the bedside to provide verbal reorientation.
The correct action addresses two immediate priorities: correcting a body position that threatens the surgical graft and managing acute confusion safely. Following a femoral-popliteal bypass, sharp flexion of the knee or hip is contraindicated because it can compress and occlude the newly placed arterial graft. Extending the leg restores proper body alignment and preserves vital blood flow. Additionally, remaining at the bedside to reorient the client serves as the least restrictive, nonpharmacological intervention for agitation and effectively prevents a potential fall.

Step-by-Step Solution

1
Analyze the client's surgical history and current physical position.
The client had an arterial bypass. The right knee is sharply flexed, which can restrict arterial blood flow and cause graft failure.
Maintaining proper body alignment and avoiding sharp flexion at the hip or knee is a critical basic care standard for vascular surgery patients.
2
Evaluate the client's psychosocial status and environmental safety.
The client is experiencing acute confusion (delirium) and is at an immediate risk for falls by attempting to climb out of bed.
Sudden disorientation requires immediate nonpharmacological comfort and safety measures, such as constant presence and reorientation.
3
Determine the most appropriate and least restrictive initial intervention.
Repositioning the leg to an extended position protects the graft, while remaining at the bedside provides safety without the use of physical restraints.
Nursing standards require implementing the least restrictive interventions first and avoiding actions that compromise arterial circulation.

Key Concept

Proper postoperative body alignment and implementation of least restrictive safety measures for acute delirium.
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Topics

Basic Care and Comfort

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