A nurse is providing care for a patient who has weak pedal pulses, no hair on both legs, and a full-thickness wound on the right lateral malleolus with defined margins, which includes a small amount of serous exudate.

Which intervention should not be performed?

Evaluate the need for smoking cessation

Apply TED hose to both legs

Consult with physical therapy

Obtain Ankle-Brachial Index (ABI) using a hand-held Doppler

Answer and Explanation

The Correct Answer is B

Choice A rationale
Evaluating the need for smoking cessation is a standard part of nursing care, especially for patients with circulatory issues. Smoking can exacerbate circulatory problems and delay wound healing.
Choice B rationale
Applying TED hose to both legs might not be appropriate for this patient. TED hose are compression stockings designed to prevent deep vein thrombosis and promote circulation. However, in a patient with weak pedal pulses and a full-thickness wound on the leg, the compression from the stockings could potentially worsen circulation to the area and impede wound healing.
Choice C rationale
Consulting with physical therapy could be beneficial for this patient. Physical therapists can provide exercises and interventions to improve circulation and mobility, which could help with the patient’s circulatory issues and wound healing.
Choice D rationale
Obtaining an Ankle-Brachial Index (ABI) using a hand-held Doppler could be useful in this situation. The ABI is a simple, non-invasive test that can help diagnose peripheral artery disease (PAD), a condition that could be causing the patient’s weak pedal pulses and wound healing issues.

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Correct Answer is C

Explanation

Choice A rationale
Adenosine (Adenocard) is a medication that can be used to treat supraventricular tachycardia, a type of abnormal heart rhythm. However, it is not typically used for atrial fibrillation.
Choice B rationale
Emergency cardioversion, where an electric shock is used to restore the heart’s normal rhythm, can be used in some cases of atrial fibrillation. However, if the atrial fibrillation has been present for more than 48 hours, there is a risk of blood clots, and anticoagulation for several weeks before the procedure may be needed.
Choice C rationale
Anticoagulant therapy is often used in patients with atrial fibrillation to reduce the risk of stroke. Atrial fibrillation can lead to blood pooling in the atria, increasing the risk of clot formation. These clots can then travel to the brain, causing a stroke.
Choice D rationale
Permanent pacemakers are sometimes used in atrial fibrillation to help regulate the heart’s rhythm. However, they are typically used when other treatments have failed or are contraindicated.

A. Adenosine B. Diltiazem C. Atropine D. Captopril

Correct Answer is B

Explanation

Choice A rationale: Adenosine Adenosine is a naturally occurring substance that relaxes and dilates blood vessels. It also affects the electrical activity of the heart. Adenosine is used to help restore normal heartbeats in people with certain heart rhythm disorders. However, it is not typically used for atrial fibrillation.

Choice B rationale: Diltiazem Diltiazem belongs to a class of medications called calcium-channel blockers. It works by relaxing the blood vessels so the heart does not have to pump as hard. Diltiazem also increases the supply of blood and oxygen to the heart. It is used in adults alone or in combination with other medications to treat hypertension (high blood pressure) or symptoms of angina (chest pain). Diltiazem injection is used in adults to treat certain heart rhythm disorders such as atrial fibrillation.

Choice C rationale: Atropine Atropine is a tropane alkaloid and anticholinergic medication used to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate, and to decrease saliva production during surgery. However, it is not typically used for atrial fibrillation.

Choice D rationale: Captopril Captopril is used in adults alone or in combination with other medications to treat high blood pressure (hypertension) and congestive heart failure.
Captopril is also used to improve survival and reduce the risk of heart failure after a heart attack in patients with a heart condition called left ventricular hypertrophy (enlargement of the walls of the left side of the heart)4. However, it is not typically used for atrial fibrillation.

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A nurse is providing care for a patient who has weak pedal pulses, no hair on both legs, and a full-thickness wound on the right lateral malleolus with defined margins, which includes a small amount of serous exudate. Which intervention should not be performed?

Nursing Test Bank

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A patient with dilated cardiomyopathy has recently developed atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

Correct Answer is C

Explanation

The nurse is providing care for a patient with the following tracing on the electrocardiogram (ECG) for atrial fibrillation. What prescription should the nurse anticipate from the primary healthcare provider (PHCP)?

Correct Answer is B

Explanation

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A nurse is providing care for a patient who has weak pedal pulses, no hair on both legs, and a full-thickness wound on the right lateral malleolus with defined margins, which includes a small amount of serous exudate.

Which intervention should not be performed?