A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs the skin is pale and cool to touch. The nurse notes small circular ulcers on the soles of his feet. From these findings, the nurse knows that the client has a problem with circulation. Which of the circulation condition does the nurse suspect?
Necrotic wound
Trauma
Venous insufficiency
Arterial insufficiency
The Correct Answer is D
The findings of pale and cool skin on the lower legs, along with small circular ulcers on the soles of the feet, are indicative of arterial insufficiency. Arterial insufficiency occurs when there is a decreased blood flow to the extremities, often due to conditions such as atherosclerosis or peripheral arterial disease. This reduced blood flow can result in pale and cool skin, as well as the development of ulcers, which are typically round and have well-defined borders. It is essential to assess and manage arterial insufficiency promptly to prevent complications like tissue necrosis and gangrene.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["438"]
Explanation
To calculate the high-end dosage for a 125 kg patient, you can multiply the weight in kilograms (125 kg) by the high-end dosage range (3.5 mg/kg):
High-end dosage = 125 kg * 3.5 mg/kg = 437.5 mg
Rounded to whole number give 438mg.
Correct Answer is C
Explanation
A. Manage bladder irrigation following the procedure. - Bladder irrigation is not typically performed after ESWL. It may be used in other urological procedures, but it is not a standard post-procedural care for ESWL.
B. Administer a bolus of 750 mL normal saline following the procedure. - While maintaining hydration is important, there is no specific requirement for a bolus of normal saline after ESWL. Hydration is usually encouraged, but the amount and method of administration are determined based on the client's overall fluid status and medical condition.
C. Strain the client's urine following the procedure.
After extracorporeal shock wave lithotripsy (ESWL), it is essential to strain the client's urine to collect any stone fragments. Straining allows healthcare providers to analyze the composition of the stones, ensuring that all fragments have been passed. This information helps in assessing the effectiveness of the procedure and guides further management.
D. Insert a urinary catheter for 24 to 48 hours after the procedure. - Inserting a urinary catheter is not a routine post-procedural measure after ESWL. Catheterization might be necessary in certain situations or for specific medical reasons, but it is not a standard practice after ESWL for all clients.
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