An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg, consistent with acute arterial occlusion.
After the nurse notifies the healthcare provider, what should the nurse do next?
Elevate the leg above the level of the heart.
Assist the patient in gently exercising the leg.
Apply a compression stocking to the leg.
Keep the patient in bed in the supine position.
The Correct Answer is D
Choice A rationale
Elevating the leg above the level of the heart would not be beneficial in this case. This action would actually reduce blood flow to the leg, which is already compromised due to the arterial occlusion.
Choice B rationale
Exercising the leg would increase the oxygen demand of the tissues in the leg, which could exacerbate the problem. The tissues in the leg are already deprived of oxygen due to the arterial occlusion.
Choice C rationale
Applying a compression stocking to the leg would not be beneficial in this case. This action would further compromise blood flow to the leg, which is already reduced due to the arterial occlusion.
Choice D rationale
Keeping the patient in bed in the supine position is the correct action. This position will decrease the oxygen demand of the tissues in the leg and minimize ischemic damage until circulation can be restored.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Rheumatoid arthritis is an autoimmune disease that primarily affects the joints. While it can increase the risk of cardiovascular disease due to systemic inflammation, it is not typically considered a direct cause of secondary hypertension.
Choice B rationale
Coarctation of the aorta, a congenital condition characterized by a narrowing of the aorta, can cause secondary hypertension. This is because the narrowing can increase resistance to blood flow, leading to increased pressure.
Choice C rationale
Increased intracranial pressure (ICP) can cause secondary hypertension as part of Cushing’s reflex, a physiological response to protect the brain from damage. This reflex can lead to an increase in systemic blood pressure in an attempt to maintain cerebral perfusion.
Choice D rationale
Renal disease is a common cause of secondary hypertension. The kidneys play a crucial role in regulating blood pressure, and damage to the kidneys can lead to hypertension.
Choice E rationale
Colon cancer is not typically associated with secondary hypertension. While some cancers can produce substances that increase blood pressure, colon cancer is not commonly associated with this phenomenon.
Correct Answer is D
Explanation
Choice A rationale
Homocysteine is an amino acid that your body uses to make protein and to build and maintain tissue. But too much homocysteine in your blood might increase your risk of heart disease.
However, it is not the most specific marker for AMI.
Choice B rationale
C-reactive protein (CRP) is produced by the liver and its level rises when there is inflammation in your body. While its level can increase in those with a heart attack, it is not the most specific marker for AMI6.
Choice C rationale
Myoglobin is a small protein that stores oxygen. It is measured occasionally. Myoglobin is sometimes measured in addition to troponin to help diagnose a heart attack. However, it is not as specific as cardiac-specific troponin.
Choice D rationale
Cardiac-specific troponin is a cardio-specific, highly sensitive marker for myocardial damage. The absolute cardiospecificity of cTnI allows the diagnosis of myocardial infarction distinct from muscle lesions and non-cardiac surgery.
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