An obese post-surgical patient reports sudden discomfort in her leg.

Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?

Venous thrombosis.

Paresthesia.

Vascular spasm.

Arterial occlusion.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Venous thrombosis is a condition in which a blood clot forms in a vein, typically in the leg. While this condition can cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice B rationale
Paresthesia refers to abnormal sensations in the body, such as tingling, numbness, or burning. While this condition could potentially cause discomfort, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice C rationale
Vascular spasm is a sudden, brief tightening of the muscles inside the walls of a blood vessel. While this could potentially cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice D rationale
Arterial occlusion is the correct answer. This condition involves a blockage in an artery, which can significantly reduce blood flow to the affected area. This could cause the leg to become cold and pale and result in the loss of a pulse.

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Correct Answer is C

Explanation

Choice A rationale
Adenosine (Adenocard) is a medication that can be used to treat supraventricular tachycardia, a type of abnormal heart rhythm. However, it is not typically used for atrial fibrillation.
Choice B rationale
Emergency cardioversion, where an electric shock is used to restore the heart’s normal rhythm, can be used in some cases of atrial fibrillation. However, if the atrial fibrillation has been present for more than 48 hours, there is a risk of blood clots, and anticoagulation for several weeks before the procedure may be needed.
Choice C rationale
Anticoagulant therapy is often used in patients with atrial fibrillation to reduce the risk of stroke. Atrial fibrillation can lead to blood pooling in the atria, increasing the risk of clot formation. These clots can then travel to the brain, causing a stroke.
Choice D rationale
Permanent pacemakers are sometimes used in atrial fibrillation to help regulate the heart’s rhythm. However, they are typically used when other treatments have failed or are contraindicated.

A. A patient who experienced dizziness after the first dose of captopril. B. A patient exhibiting new-onset confusion, restlessness, and cool, clammy skin. C. A patient on oxygen therapy with bilateral crackles at the lung bases. D. A patient on IV nesiritide (Natrecor) with a blood pressure reading of 100/62.

Correct Answer is B

Explanation

Choice A rationale
While dizziness after the first dose of captopril can be concerning, it is not uncommon as the body adjusts to the medication. It is important to monitor this patient, but they are not the highest priority.
Choice B rationale
A patient exhibiting new-onset confusion, restlessness, and cool, clammy skin should be prioritized for assessment. These symptoms could indicate a serious condition such as shock or decreased cardiac output. This patient may be experiencing a rapid decline in condition and should be assessed immediately.
Choice C rationale
While a patient on oxygen therapy with bilateral crackles at the lung bases may have worsening heart failure, they are not the highest priority if they are stable. Crackles at the lung bases are a common finding in heart failure and indicate fluid accumulation in the lungs.
Choice D rationale
A patient on IV nesiritide (Natrecor) with a blood pressure reading of 100/62 is not the highest priority. While this blood pressure is on the lower side, it is not critically low.
Nesiritide can cause hypotension, so this patient should be monitored, but they are not the highest priority if they are stable.

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An obese post-surgical patient reports sudden discomfort in her leg. Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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An obese post-surgical patient reports sudden discomfort in her leg.

Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?