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

Fluid Volume Excess (FVE), or hypervolemia, refers to an isotonic expansion of the ECF due to an increase in total body sodium content and an increase in total body water. This fluid overload usually occurs from compromised regulatory mechanisms for sodium and water as seen commonly in heart failure (CHF), kidney failure, and liver failure. The key signs of hypervolemia include weight gain and swelling. One of the defining characteristics of FVE is an increase in urine specific gravity. Therefore, a urine specific gravity of 1.012 can validate the problem of Fluid Volume Excess for a patient.

Choice B rationale

+4 Pedal pulses indicate a very bounding and strong pulse, which is not directly related to Fluid Volume Excess. While it might be observed in some cases due to increased blood volume and pressure, it is not a specific or primary indicator of this condition.

Choice C rationale

A respiratory rate of 20/minute is within the normal range for an adult (12-20 breaths per minute) and does not specifically indicate Fluid Volume Excess. While respiratory changes can occur with severe or prolonged Fluid Volume Excess, a normal respiratory rate does not validate this diagnosis.

Choice D rationale

A potassium level of 3.8 mEq/L is within the normal range (3.5-5.0 mEq/L) and does not specifically indicate Fluid Volume Excess. While electrolyte imbalances can occur with Fluid Volume Excess, a normal potassium level does not validate this diagnosis.

A. Heparin makes the blood less thick and easier to flow. B. Heparin dissolves the clot and decreases the formation of platelets. C. Heparin does not thin the blood; it prevents new clots from forming. D. Heparin decreases the number of platelets so the blood flows more easily.

Correct Answer is C

Explanation

Choice A rationale

Heparin does not actually thin the blood or make it less thick. Instead, it works by increasing the activity of antithrombin, a protein that inhibits blood clotting. This prevents new clots from forming and existing clots from growing larger.

Choice B rationale

Heparin does not dissolve clots or decrease the formation of platelets. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa, two key players in the blood clotting process.

Choice C rationale

This statement is accurate. Heparin does not thin the blood; instead, it prevents new clots from forming and existing clots from growing larger. It does this by increasing the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

Choice D rationale

Heparin does not decrease the number of platelets or make the blood flow more easily. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies the problem of Fluid Volume Excess for a patient. Which assessment finding validates this problem?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A patient diagnosed with deep vein thrombosis asks the nurse, “How does this blood thinner heparin work?” Which response is most accurate?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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?

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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?