A nurse is caring for a client with peripheral arterial disease (PAD). Which of the following interventions should the nurse include in the plan of care?

Encourage strict bed rest with tuning and repositioning every 2 hours.

Have the client dangle" their legs several times per day and when pain occurs,

Have the client elevate their legs above heart level when pain occurs

Have the client use ice packs to relieve lower extremity pain.

Answer and Explanation

The Correct Answer is B

A) "Encourage strict bed rest with turning and repositioning every 2 hours":
. For clients with peripheral arterial disease (PAD), strict bed rest is not recommended unless the client is in severe pain or experiencing complications like ulcers or gangrene. In PAD, exercise and mobility are essential for improving blood flow and reducing symptoms. Prolonged immobility could worsen circulation and lead to complications like muscle atrophy. Therefore, encouraging gentle movement and activity, like walking or repositioning, is typically more beneficial than prolonged bed rest.

B) "Have the client 'dangle' their legs several times per day and when pain occurs":
. For clients with PAD, dangling the legs can be helpful in alleviating pain and discomfort. When the client dangles their legs, gravity helps to increase blood flow to the lower extremities, which can provide temporary relief from symptoms like intermittent claudication (pain caused by insufficient blood flow). It is important to balance this with the advice to avoid elevating the legs, as elevating them above the heart level may decrease arterial perfusion, worsening symptoms.

C) "Have the client elevate their legs above heart level when pain occurs":
. Elevating the legs above the heart level in clients with PAD may worsen symptoms. In PAD, blood flow to the legs is already compromised, and elevating the legs above the heart can further reduce arterial blood flow to the lower extremities, increasing pain and discomfort. Instead, dangling the legs or lying flat with the legs at heart level is generally better for improving circulation.

D) "Have the client use ice packs to relieve lower extremity pain":
. Applying ice packs is not recommended for clients with PAD, as cold can cause vasoconstriction, further reducing blood flow to already compromised tissues. Cold therapy may increase pain and lead to tissue damage in individuals with reduced circulation. The nurse should instead focus on strategies that promote blood flow, such as encouraging gentle exercise, dangling the legs, or using warmth (in some cases) to improve circulation.

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 A

Explanation

A) Explaining the purpose, risks, benefit, and alternatives of the surgery: This is not the responsibility of the RN. The role of explaining the purpose, risks, benefits, and alternatives of the surgery falls under the responsibility of the surgeon or the healthcare provider performing the procedure. The RN can provide general information and support but is not responsible for explaining the details of the surgery or obtaining informed consent.

B) Witnessing the client’s signature on the consent form: This is within the RN’s scope of practice. The nurse's role in the consent process is to witness the client's signature, ensuring that it is voluntary and that the client appears to be competent and informed. The nurse does not explain the details of the procedure, but they confirm that the patient has been informed by the surgeon.

C) Conducting a baseline physical assessment and obtaining vital signs: This is an important responsibility of the RN. The nurse conducts a thorough pre-operative assessment, which includes gathering baseline physical data and vital signs. This helps establish a reference point for the client’s health status before surgery and allows for the identification of any abnormalities that may need to be addressed.

D) Ensuring the pre-operative checklist is completed: This is also the RN's responsibility. The nurse ensures that all aspects of the pre-operative checklist, which includes verifying consent, ensuring necessary tests are done, and confirming that the patient is prepared for surgery, are completed. This is part of the nurse’s role in preparing the patient for a safe surgical experience.

A. Having the patient splint their incision site when coughing and deep breathing B. Offering around the clock pain medication the immediate post operative phase C. Administering prescribed pre-operative antibiotics within 30-60 minutes of surgery. D. Performing the first dressing change on a new surgical site in the post operative setting

Correct Answer is C

Explanation

A. Having the patient splint their incision site when coughing and deep breathing:
While splinting the incision site can help alleviate pain and prevent strain on the surgical wound during coughing and deep breathing, it is not a primary intervention for preventing surgical site infection. Infection prevention is more directly related to sterile technique, antibiotic prophylaxis, and maintaining a clean environment around the wound. Splinting can support postoperative recovery, but it does not directly prevent infection.

B. Offering around the clock pain medication in the immediate post-operative phase:
Providing pain medication is important for patient comfort and to facilitate early mobilization after surgery. However, pain management does not directly prevent surgical site infections. The focus for infection prevention lies in maintaining sterility, administering antibiotics as prescribed, and appropriate wound care rather than pain control alone.

C. Administering prescribed pre-operative antibiotics within 30-60 minutes of surgery:
The administration of prophylactic antibiotics before surgery, typically within 30-60 minutes of the incision, is a primary intervention for preventing surgical site infections (SSIs). This timing ensures that the antibiotics are at therapeutic levels in the bloodstream when the surgical procedure begins, reducing the risk of introducing bacteria into the surgical site. This is a well-established guideline for infection prevention in surgical settings.

D. Performing the first dressing change on a new surgical site in the postoperative setting:
The first dressing change should generally be done by a healthcare professional using sterile technique. However, the timing and handling of the first dressing change are more related to wound care practices rather than a primary strategy for preventing infection. Infection prevention primarily involves proper antibiotic prophylaxis, maintaining a sterile field, and managing the surgical site during the early post-operative period. The first dressing change, while important for wound healing, is not the most immediate or primary intervention for preventing surgical site infection.

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 nurse is caring for a client with peripheral arterial disease (PAD). Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for surgery in ine pre-operative setting. Which of the following is not the responsibility of the RN?

Correct Answer is A

Explanation

The nurse identifies which of the following as one of the primary nursing interventions for preventing surgical site infection?

Correct Answer is C

Explanation

The nurse is caring for an older adult client who is at risk for falls. Which of the following interventions should be included in the plan of care for this client?

The nurse is caring for a patient who was admitted for seizures. All of the following precautions should be taken to promote a safe environment except which?

The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

A nurse is providing education for client newly prescribed warfarin in preparation for being discharged home. Which of the following should be included the teaching plan? (Select all that apply.)

The nurse is providing education to a client newly diagnosed gastroesophageal reflux (GERD). Which of the following would be an incorrect statement about this condition?

The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse’s priority for planning care?

A nurse is preparing to administer dextromethorphan 30 mg PO. The amount available is dextromethorphan oral liquid 7.5 mg/5mL. How many should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

You enter the room of your known diabetic patient and find them unresponsive. After ensuring they are breathing and have a patent airway, you check a blood glucose and find it to be 30 mg/dL. Which of the following medications should be the priority to administer?