A patient has returned to the unit following a peripheral artery angiogram with a stent insertion.
Four hours post-procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cold and dusky. What should be the nurse’s immediate action?

Reposition the limb and reassess.

Apply a warm blanket.

Notify the healthcare provider.

Elevate the extremity on a pillow.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While repositioning the limb and reassessing might be a part of the overall evaluation, it should not be the immediate action. The symptoms described are indicative of a serious issue that requires immediate medical attention.

Choice B rationale

Applying a warm blanket will not address the underlying issue. The symptoms described suggest a problem with circulation that needs immediate medical attention.

Choice C rationale

Notifying the healthcare provider is the correct immediate action. The symptoms described suggest that the patient may be experiencing a complication such as occlusion of the stent. This is a medical emergency that requires immediate intervention.

Choice D rationale

Elevating the extremity on a pillow is not the immediate action to take. While elevation can help with conditions like edema, it does not address the serious symptoms the patient is experiencing.

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Correct Answer is A

Explanation

Choice A rationale

Intermittent claudication, which involves limb pain or cramping that generally begins when exercising and improves while resting, is a common symptom in the early stages of PAD5.

Choice B rationale

Foot ulcers are not typically a symptom of the early stages of PAD. They are more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.

Choice C rationale

Pain at rest is not typically a symptom of the early stages of PAD. It is more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.

Choice D rationale

Dependent rubor is not typically a symptom of the early stages of PAD. It is more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.

A. Have the client drink 4 oz. of orange juice B. Give the client 3 tbsp. C. of sugar dissolved in 4 oz. of grape juice to drink D. Monitor the client closely until dinner arrives

Correct Answer is A

Explanation

Step 1 is to understand that a blood glucose level of 50 mg/dL is considered hypoglycemic. Immediate treatment is necessary to raise the blood glucose level.

Step 2 is to follow the 15-15 rule for treating hypoglycemia, which recommends consuming 15 grams of carbohydrates and then checking blood glucose levels after 15 minutes. Four ounces of orange juice contains about 15 grams of carbohydrates and can quickly raise blood glucose levels.

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A patient has returned to the unit following a peripheral artery angiogram with a stent insertion. Four hours post-procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cold and dusky. What should be the nurse’s immediate action?

Choice B rationale

Choice C rationale

Choice D rationale

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has peripheral arterial disease (PAD). What symptoms should the nurse expect to find in the early stage of the disease?

Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A Type 1 diabetic client’s blood glucose level is 50 mg/dL at 16:30. The client is alert; however, dinner will not be served until 17:15. What should be the nurse’s initial action?

Correct Answer is A

Explanation

The client newly diagnosed with Type 1 diabetes is to be discharged in the morning and has received no instruction on diabetes. What should be the nurse’s teaching priority?

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A patient has returned to the unit following a peripheral artery angiogram with a stent insertion.
Four hours post-procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cold and dusky. What should be the nurse’s immediate action?