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.

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Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

A. Tamsulosin primarily affects urinary function and is not directly related to glucose metabolism or insulin action. It does not significantly contribute to hypoglycemic events.
B. While urinary retention can lead to discomfort and potential complications, it does not have a direct impact on blood glucose levels or increase the risk of hypoglycemia. However, if it results in increased stress or medication changes, it could indirectly affect glucose management.
C. Physical activity, such as jogging, can increase the risk of hypoglycemia in individuals with Type 1 diabetes, especially if they do not adjust their insulin or carbohydrate intake accordingly. Exercise can enhance insulin sensitivity and cause blood glucose levels to drop.
D. Alcohol can increase the risk of hypoglycemia, particularly in individuals with diabetes, because it can inhibit gluconeogenesis (the liver's ability to produce glucose). Drinking a significant amount of alcohol, especially without food, can lead to dangerously low blood sugar levels.
E. Metoprolol, a beta-blocker, can mask the symptoms of hypoglycemia (such as increased heart rate and tremors), making it more difficult for the individual to recognize when they are hypoglycemic. This can lead to delayed treatment and increased risk of severe hypoglycemia.

A. Use aspirin or ibuprofen for pain relief as instructed by package insert B. Omit green, leafy vegetables completely from your diet C. Obtain a medical alert bracelet D. Use an electric razor for shaving E. Obtain prothrombin time (PT) & activated partial prothrombin time as directed

Correct Answer is ["C","D","E"]

Explanation

A. Clients on warfarin should generally avoid nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen, as these can increase the risk of bleeding. Instead, acetaminophen is often recommended for pain relief, but it should be used cautiously and under a healthcare provider’s guidance.
B. While vitamin K found in green, leafy vegetables can affect warfarin levels, clients do not need to eliminate these foods entirely. Instead, they should maintain a consistent intake of vitamin K-rich foods to help manage their INR levels. Sudden changes in diet can lead to fluctuations in anticoagulation control.
C. It is important for clients taking warfarin to wear a medical alert bracelet. This alerts healthcare providers in case of an emergency, as the client may require special care due to their anticoagulant therapy.

D. Using an electric razor is a safer option for clients on warfarin as it reduces the risk of cuts and bleeding compared to using a traditional razor. This is an important safety measure for those on anticoagulation therapy.
E. Monitoring prothrombin time (PT) and International Normalized Ratio (INR) is essential for clients on warfarin to ensure they are within the therapeutic range. Regular testing helps to manage the dosage effectively and minimize the risk of bleeding or thrombosis.

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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 that which of the following activities/conditions increases complications of hypoglycemia for the individual with type 1 diabetes? (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

The nurse is providing teaching to a client who is being discharged with a prescription for warfarin. Which information should be included in the teaching for this medication? (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

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