A client has returned to the unit following a peripheral angiogram with a stent insertion. Four hours post procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cool and dusky. What should be the nurse's immediate action?

Notify the physician

Cover the limb with a blanket

Reposition the limb and reassess

Elevate the extremity on a pillow

Answer and Explanation

The Correct Answer is A

A.   The loss of a pulse and the cool, dusky appearance of the foot indicate potential complications such as thrombus formation or arterial occlusion, which require prompt medical evaluation and intervention. Notifying the physician ensures that appropriate diagnostic and therapeutic measures can be taken quickly.
B.   While keeping the client warm is important, simply covering the limb does not address the underlying issue of compromised circulation. This action could potentially delay necessary interventions that address the lack of blood flow.
C.   Although repositioning the limb might help with circulation, it is not sufficient given the critical nature of the symptoms. It is essential to first inform the physician to get guidance on further evaluation or interventions. Repositioning could also delay timely intervention needed to prevent tissue damage.
D.   Elevating the limb might worsen blood flow in a case of compromised circulation. In cases of suspected arterial occlusion, keeping the limb at heart level or below may be more appropriate to promote blood flow. Elevating it could delay necessary treatment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. While biofeedback can be a helpful technique for managing pain in the long term, it is not an immediate intervention for acute pain. The client is expressing urgent pain that requires prompt action, so this option does not address the immediate need.
B. Placing the residual limb in a dependent position (below the level of the heart) can increase swelling and may worsen the pain. After surgery, the limb should typically be elevated to minimize swelling, especially in the early postoperative period.

C. While it is important for clients to understand their situation, explaining the amputation does not provide immediate relief for acute pain. The client is likely already aware of the amputation and is in distress, so this option is not a priority at this moment.
D. This is the most appropriate intervention. The client is experiencing significant pain, and administering a narcotic analgesic can provide immediate relief. Pain management is a priority in the postoperative setting, especially in the first few hours after surgery.

A. prevents bleeding and covers the incision. B. decreases phantom limb pain. C. limits the formation of blood clots. D. shapes the soft tissue and minimizes edema.

Correct Answer is D

Explanation

A. While wrapping the stump can help secure a dressing and protect the incision, the primary purpose of the elastic bandage is not to prevent bleeding. Instead, it helps to manage swelling and shape the residual limb.
B. Phantom limb pain is a sensation where individuals feel pain in the area where the limb once was. While some patients report relief from phantom pain with various techniques, wrapping the stump is not specifically designed for this purpose. Other interventions are more effective for managing phantom limb pain.
C. Elastic bandaging does not specifically limit the formation of blood clots in the context of an amputation stump. While proper limb positioning and movement can help prevent clot formation, the main purpose of the bandage is not related to clot prevention.
D. The primary purpose of wrapping the stump with an elastic bandage is to shape the soft tissue and control edema (swelling). Proper compression helps reduce swelling, encourages the soft tissue to conform to the desired shape for fitting a prosthesis later, and aids in healing.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client has returned to the unit following a peripheral angiogram with a stent insertion. Four hours post procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cool and dusky. What should be the nurse's immediate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is three hours postoperative left leg below the knee amputation (BKA). The client tells the nurse. "My left foot is killing me. Please do something!" Which intervention should the nurse implement?

Correct Answer is D

Explanation

A client with an above the knee amputation asks the nurse why the stump needs to be wrapped with an elastic bandage. The nurse explains that it:

Correct Answer is D

Explanation

A client receives 20 units of isophane insulin suspension (NPH) insulin at 0730. The nurse teaches the client that signs of hypoglycemia are most likely to occur at what time?

A client's insulin dosage is 16 units of regular insulin in the morning. The client should be taught to expect the insulin peak within:

The client is receiving a trimethoprim-sulfamethoxazole. What information should the nurse include in the teaching about this medication?

The nurse is teaching an adult client with Type 1 diabetes that a primary cause of the development of diabetic ketoacidosis (DKA) is:

A client is receiving heparin sodium 5000 units IV and oral warfarin sodium 2.5 mg PO for thrombophlebitis in the left leg. The nurse educated the client that heparin and warfarin are both used because:

The nurse is teaching a client who is diagnosed with peripheral arterial disease about the benefits of walking to exercise. What information should the nurse reinforce with this client?

A newly admitted client has been prescribed sulfamethoxazole/trimethoprim. The nurse understands that this medication is contraindicated based on which lab result?

A client on glipizide, a sulfonylurea, reports to the nurse feeling anxious, sweaty & has a headache. The nurse's initial action is to: