A patient has returned to the unit following a peripheral arteriogram. During the assessment, the nurse notes that the dorsalis pedis pulse is not palpable and the foot is cold. What should be the nurse's immediate action?
Notify the physician of this finding
Elevate the limb on two pillows
Cover the limb with a blanket
Reposition the limb and reassess
The Correct Answer is A
A. A cold, pulseless foot indicates compromised blood flow, a medical emergency following an arteriogram. The nurse should immediately notify the physician to address potential vascular occlusion.
B. Elevating the limb can further impair circulation if blood flow is already compromised.
C. Covering the limb will not address the underlying issue of impaired circulation.
D. Repositioning may delay timely intervention in what may be a vascular emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Blood pressure monitoring is essential, as spinal cord injuries at high levels can cause disruptions in autonomic regulation, leading to significant blood pressure fluctuations.
B. Bladder function is impacted by spinal cord injuries; however, it is not the initial priority in an emergency setting when life-threatening complications must be managed first.
C. Heart rate is critical as high spinal cord injuries can impact cardiac function by affecting autonomic control, potentially leading to bradycardia.
D. Reflexes are often assessed in cases of spinal injury, but they are not the immediate priority when stabilizing the patient upon arrival.
E. Respirations are a priority, as a C1 spinal cord injury can compromise respiratory function, necessitating immediate assessment to ensure adequate oxygenation and airway management.
Correct Answer is B
Explanation
A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.
B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.
C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.
D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.
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