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.

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Correct Answer is B

Explanation

A) Obtaining a primary and secondary tubing set:
The primary tubing is used for the intravenous access, and the secondary tubing is attached for administering the blood product. This ensures that the blood transfusion will be delivered effectively, and it is a standard practice to use proper IV tubing for blood products to avoid contamination or complications.

B) Ensuring another licensed personnel is available:
. While it is required that two licensed healthcare professionals verify the blood product before starting the transfusion, this action itself is not contraindicated, it is required. Both individuals should independently check the patient's identification, blood type, and the matching of the blood product before administration. Therefore, the answer to the question should not be about ensuring availability of licensed personnel as this is actually a required safety measure, not contraindicated. The actual contraindications involve actions like using inappropriate fluids for transfusion or mismatching blood.

C) Obtaining 0.9% normal saline solution:
This is appropriate and necessary when preparing for a blood transfusion. Normal saline (0.9%) is the only compatible solution that should be used to flush the IV line before and after the transfusion or to prime the blood tubing. Other solutions, such as lactated Ringer's, can cause clotting when mixed with blood, making saline the only appropriate choice.

D) Checking ABO and Rh status of the donor and recipient:
This is essential and mandatory before administering a blood transfusion. It is critical to ensure that the ABO blood group and Rh factor of the donor and recipient are compatible to prevent hemolytic reactions. This compatibility check must be done every time before administering a transfusion, and it is an integral part of ensuring patient safety.

A. "If I develop a fever, I will tell my doctor at the next scheduled office appointment." B. I will avoid hugging my family, so that I don't give them the virus." C. "I can still have my favorite sushi occasionally as long as I wear a mask to the restaurant." D. I will need to take the medications even when the virus is well-controlled."

Correct Answer is D

Explanation

A) "If I develop a fever, I will tell my doctor at the next scheduled office appointment."
. Clients with HIV should not wait for their next scheduled appointment to report any signs of infection or complications. Fever, as well as other symptoms such as cough, fatigue, or skin rashes, may indicate a potential infection or opportunistic infection that requires immediate medical attention. Early intervention can prevent complications. Therefore, the nurse should emphasize the importance of reporting any symptoms of illness immediately to the healthcare provider.

B) "I will avoid hugging my family, so that I don't give them the virus."
. HIV is not transmitted through casual contact such as hugging, shaking hands, or sharing meals. HIV is transmitted through blood, semen, vaginal fluids, breast milk, and through needle sharing or sexual contact. It is important for patients with HIV to understand that they can continue to engage in normal daily activities and maintain close relationships with family members and friends without the fear of spreading HIV through non-bodily fluid contact.

C) "I can still have my favorite sushi occasionally as long as I wear a mask to the restaurant."
. The need to wear a mask to prevent HIV transmission is a misconception. HIV is not transmitted through food, air, or casual social interactions. The concern regarding eating sushi comes from the risk of foodborne illness, particularly for individuals with compromised immune systems, such as those with HIV. Raw or undercooked food (like sushi) can expose individuals to bacterial, viral, or parasitic infections, which are more harmful to immunocompromised clients. Safe food handling practices and avoiding raw or undercooked foods are more important than wearing a mask.

D) "I will need to take the medications even when the virus is well-controlled."
. Adherence to antiretroviral therapy (ART) is essential for people living with HIV, even when the virus is well-controlled and their viral load is undetectable. Stopping or interrupting ART can lead to drug resistance and a return of the virus. Consistent medication use is the key to preventing the progression of HIV, reducing viral transmission, and maintaining long-term health. The patient should be educated about the importance of taking ART as prescribed for life, even when feeling well, to keep the virus suppressed and prevent complications

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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?

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