During the assessment of the patient, the nurse finds nonpalpable pedal pulses in the affected leg. How will the nurse proceed with assessment?

Have the primary provider prescribe a CT

Apply a tourniquet for 3 to 5 minutes and then reassess

Elevate the extremity and attempt to palpate the pulses

Use the doppler ultrasound to detect pedal pulses

Answer and Explanation

The Correct Answer is D

A. Having the primary provider prescribe a CT:
Prescribing a CT scan is not the initial action for assessing nonpalpable pedal pulses. CT scans are typically used for imaging purposes and are not the primary diagnostic tool for assessing peripheral pulses.

B. Apply a tourniquet for 3 to 5 minutes and then reassess:
While applying a tourniquet may increase the visibility of pulses in some cases, it is not the recommended method for assessing pedal pulses, especially if they are nonpalpable. Tourniquet use carries risks, such as tissue damage or ischemia, and is not a standard practice for assessing pulses.

C. Elevate the extremity and attempt to palpate the pulses:
Elevating the extremity may improve blood flow and make pulses easier to palpate, but if the pulses are nonpalpable, simply elevating the extremity may not be sufficient for assessment. Additionally, palpation alone may not accurately detect pulses in some cases.

D. Use the doppler ultrasound to detect pedal pulses:
This is the most appropriate action. Doppler ultrasound is a non-invasive diagnostic tool commonly used to assess peripheral pulses, especially when they are nonpalpable. It uses sound waves to detect blood flow and can provide accurate information about the presence and strength of pedal pulses. Using a doppler ultrasound can help confirm the status of pedal pulses and guide further management.

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Correct Answer is A

Explanation

A. Using appropriate personal protective equipment (PPE): Standard precautions include the use of PPE such as gloves, masks, gowns, and eye protection when caring for all patients, regardless of their known or suspected infectious status. This helps prevent the transmission of pathogens between the patient and the healthcare provider.

B. Placing patient in positive pressure isolation room: Placing a patient in a positive pressure isolation room is not a component of standard precautions. Positive pressure rooms are typically used for patients with compromised immune systems to protect them from exposure to airborne pathogens. Standard precautions should be followed regardless of the patient's room type.

C. Placing patient in contact precautions: Contact precautions involve specific measures to prevent the transmission of pathogens through direct or indirect contact with the patient or their environment. While contact precautions may be necessary for certain infectious diseases, they are not a component of standard precautions.

D. Wearing gloves at all times: While wearing gloves is part of standard precautions, it is not the only key element. Standard precautions also include other forms of PPE such as masks, gowns, and eye protection, as well as other infection control practices such as hand hygiene and environmental cleaning.

A. Let your provider know if a new cough occurs B. Take the medication on a full stomach C. This medication will not cause edema D. Eat a high potassium diet

Correct Answer is A

Explanation

A. Let your provider know if a new cough occurs:
This teaching is essential because lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, is associated with a potential side effect of a persistent, dry cough. Notifying the healthcare provider if a new cough develops allows for appropriate management, such as discontinuation or adjustment of the medication to alleviate the symptom.

B. Take the medication on a full stomach:
Taking lisinopril with or without food is acceptable, as it does not significantly affect its absorption. However, taking it on an empty stomach is often recommended to optimize absorption. Advising the patient to take the medication on a full stomach is incorrect and may lead to misunderstandings.

C. This medication will not cause edema:
Lisinopril, as an ACE inhibitor, may actually cause or exacerbate edema as a side effect. It can lead to vasodilation and fluid retention, particularly in susceptible individuals. Providing incorrect information about the medication's potential side effects can compromise patient understanding and safety.

D. Eat a high potassium diet:
Lisinopril can increase serum potassium levels, so instructing the patient to consume a high-potassium diet may exacerbate this effect and lead to hyperkalemia. While dietary potassium intake should be monitored, advising a high-potassium diet without proper guidance can pose risks to the patient's health.

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