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
Explanation
Choice A rationale
Evaluating the need for smoking cessation is a standard part of nursing care, especially for patients with circulatory issues. Smoking can exacerbate circulatory problems and delay wound healing.
Choice B rationale
Applying TED hose to both legs might not be appropriate for this patient. TED hose are compression stockings designed to prevent deep vein thrombosis and promote circulation. However, in a patient with weak pedal pulses and a full-thickness wound on the leg, the compression from the stockings could potentially worsen circulation to the area and impede wound healing.
Choice C rationale
Consulting with physical therapy could be beneficial for this patient. Physical therapists can provide exercises and interventions to improve circulation and mobility, which could help with the patient’s circulatory issues and wound healing.
Choice D rationale
Obtaining an Ankle-Brachial Index (ABI) using a hand-held Doppler could be useful in this situation. The ABI is a simple, non-invasive test that can help diagnose peripheral artery disease (PAD), a condition that could be causing the patient’s weak pedal pulses and wound healing issues.
Correct Answer is D
Explanation
Choice A rationale
Aortic regurgitation is a condition where the aortic valve doesn’t close tightly, causing blood to leak back into the left ventricle. This condition can lead to left heart failure but is not typically associated with right heart failure.
Choice B rationale
Mitral regurgitation is a disorder in which the mitral valve on the left side of the heart does not close properly. This condition can lead to left heart failure but is not typically associated with right heart failure.
Choice C rationale
Aortic stenosis is a narrowing of the aortic valve opening. This condition can lead to left heart failure but is not typically associated with right heart failure.
Choice D rationale
Tricuspid regurgitation is a disorder in which the heart’s tricuspid valve does not close properly, causing blood to flow backward into the right atrium. This condition can lead to right heart failure, especially when associated with pulmonary hypertension.
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