167) ANSWER

D) Palpate peripheral pulses q2-4h.

RATIONALE

Pulses are assessed frequently to ensure that adequate circulation is present and an occlusion or leakage of the graft has not occurred. Pulses should be marked preoperatively so the nurse has a comparison point postoperatively. Pulses could be absent for the short-term postoperatively due to vasospasm or hypothermia. Recall that assessment is the first step in the nursing process. Option 4 reflects an assessment.