A patient with peripheral arterial disease (PAD) is sitting in a chair and has cool feet that are reddish-purple in color. What action should the nurse take?
Notify the physician.
Evaluate the distal pulses.
Have the patient lie in bed with a pillow under the knees.
Cover the patient with a blanket.
The Correct Answer is B
Choice A reason: Notifying the physician is important, but it is not the immediate action to take. The nurse should first assess the patient's condition before contacting the physician.
Choice B reason: Evaluating the distal pulses is the correct action because it provides information on the blood flow to the extremities, which is crucial for patients with PAD.
Choice C reason: Having the patient lie in bed with a pillow under the knees is not recommended for PAD patients as it can decrease blood flow to the lower extremities.
Choice D reason: Covering the patient with a blanket may provide comfort, but it does not address the underlying issue of impaired blood flow in PAD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Antiembolism stockings are designed to apply pressure to the lower legs, promoting blood circulation and preventing blood from pooling in the veins, which can lead to venous stasis.
Choice B reason: While antiembolism stockings aid in circulation, they do not replace the need for postoperative leg exercises, which are important for recovery.
Choice C reason: These stockings are not specifically used to prevent varicose veins; their primary purpose is to prevent deep vein thrombosis (DVT) in postoperative patients.
Choice D reason: The stockings are not primarily used for pain reduction; their main function is to improve venous return and prevent DVT.
Correct Answer is A
Explanation
Choice A reason: For a client with borderline personality disorder, the priority is to ensure safety, which includes protecting them from self-harm behavior, as they may have impulsive tendencies that can lead to self-injury.
Choice B reason: While providing strategies for redirecting violent behavior is important, it is secondary to ensuring the client's immediate safety.
Choice C reason: Exploring reasons for behavior is a therapeutic intervention that can help in the long term but is not the immediate priority.
Choice D reason: Encouraging the client to talk about their feelings is part of ongoing therapy but does not take precedence over ensuring the client's safety.
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