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
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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
This timing allows for 30 minutes after administration. Since insulin lispro starts working in about 15 minutes, having breakfast at this time ensures that the client’s blood sugar is managed effectively without risking hypoglycemia.
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