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
Explanation
A. Kaposi's Sarcoma is a cancer commonly associated with AIDS, characterized by purple or brown lesions on the skin and mucous membranes. It is linked to human herpesvirus-8 (HHV-8) and is often seen in immunocompromised individuals.
B. Candidiasis stomatitis involves oral or esophageal thrush, presenting as white patches rather than purple or brown lesions.
C. Cryptosporidiosis is a parasitic infection causing severe diarrhea but does not manifest as skin lesions.
D. Meningitis can cause neurological symptoms and systemic infection but does not present with purple or brown skin spots.
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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